Provider Demographics
NPI:1457009995
Name:RESERVE DIAGNOSTIC LAB
Entity Type:Organization
Organization Name:RESERVE DIAGNOSTIC LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:CHANDRESH
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-443-8523
Mailing Address - Street 1:9032 TYNE TRL
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76118-7501
Mailing Address - Country:US
Mailing Address - Phone:844-257-3737
Mailing Address - Fax:
Practice Address - Street 1:2010S SE 1ST ST
Practice Address - Street 2:
Practice Address - City:MINERAL WELLS
Practice Address - State:TX
Practice Address - Zip Code:76067-5605
Practice Address - Country:US
Practice Address - Phone:844-257-3737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-14
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45D2251692OtherCLIA