Provider Demographics
NPI:1376592279
Name:PROFESSIONAL CLINICAL LABORATORY, INC.
Entity Type:Organization
Organization Name:PROFESSIONAL CLINICAL LABORATORY, INC.
Other - Org Name:PROLAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-776-5221
Mailing Address - Street 1:3020 WICHITA CT
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76140-1710
Mailing Address - Country:US
Mailing Address - Phone:866-776-5221
Mailing Address - Fax:817-568-1960
Practice Address - Street 1:109 FAIRMONT PLZ
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-3424
Practice Address - Country:US
Practice Address - Phone:866-776-5221
Practice Address - Fax:817-568-1960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4490761Medicaid
LA1523402Medicaid
AL690000082Medicaid
MS06408362Medicaid
MS690000082Medicare PIN