Provider Demographics
NPI:1447580758
Name:PAMELA ADENUGA
Entity Type:Organization
Organization Name:PAMELA ADENUGA
Other - Org Name:HIS GRACE LAB COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:ADENUGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-704-8081
Mailing Address - Street 1:1901 SOUTHEAST PKWY
Mailing Address - Street 2:SUITE 106
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76018-3605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1901 SOUTHEAST PKWY
Practice Address - Street 2:SUITE 106
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76018-3605
Practice Address - Country:US
Practice Address - Phone:817-704-8081
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HIS GRACE MEDICAL SUPPLY AND MORE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-08
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D1091543291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45D1091543OtherCLIA