Provider Demographics
NPI:1477501435
Name:LAB-VANTAGE, INC
Entity Type:Organization
Organization Name:LAB-VANTAGE, INC
Other - Org Name:LAB VANTAGE
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KENG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-808-9900
Mailing Address - Street 1:510 GORDON ST
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78404-2514
Mailing Address - Country:US
Mailing Address - Phone:361-808-9900
Mailing Address - Fax:361-808-9911
Practice Address - Street 1:510 GORDON ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-2514
Practice Address - Country:US
Practice Address - Phone:361-808-9900
Practice Address - Fax:361-808-9911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCL5096OtherBCBS #
TXCL5096OtherBCBS #