Provider Demographics
NPI:1407240740
Name:EAST TEXAS REFERRAL AND TESTING, LLC
Entity Type:Organization
Organization Name:EAST TEXAS REFERRAL AND TESTING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF LEGAL
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VISKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:972-630-6443
Mailing Address - Street 1:9301 N CENTRAL EXPY
Mailing Address - Street 2:335D
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-0806
Mailing Address - Country:US
Mailing Address - Phone:972-630-6420
Mailing Address - Fax:972-630-6421
Practice Address - Street 1:9301 N CENTRAL EXPY
Practice Address - Street 2:335D
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-0806
Practice Address - Country:US
Practice Address - Phone:972-630-6420
Practice Address - Fax:972-630-6421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-25
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D2090810291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory