Provider Demographics
NPI:1497173348
Name:SPECTRUM DIAGNOSTIC LABS, LLC
Entity Type:Organization
Organization Name:SPECTRUM DIAGNOSTIC LABS, LLC
Other - Org Name:SPECTRUM DIAGNOSTIC LABS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PERRY
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:HOLLOWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:682-622-8858
Mailing Address - Street 1:512 N HAMPTON RD # 261
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-4920
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:209 BILLINGS ST
Practice Address - Street 2:420
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76010-2474
Practice Address - Country:US
Practice Address - Phone:682-622-8858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-28
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory