Provider Demographics
NPI:1407398241
Name:CEDAR CREEK LABS LLC
Entity Type:Organization
Organization Name:CEDAR CREEK LABS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUGGEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-714-9996
Mailing Address - Street 1:4200 BURCH DR STE C9
Mailing Address - Street 2:
Mailing Address - City:DEL VALLE
Mailing Address - State:TX
Mailing Address - Zip Code:78617-3234
Mailing Address - Country:US
Mailing Address - Phone:511-714-9996
Mailing Address - Fax:888-793-0432
Practice Address - Street 1:4200 BURCH DR STE C9
Practice Address - Street 2:
Practice Address - City:DEL VALLE
Practice Address - State:TX
Practice Address - Zip Code:78617-3234
Practice Address - Country:US
Practice Address - Phone:511-714-9996
Practice Address - Fax:888-793-0432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-10
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D2010541291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45D2010541OtherCLIA