Provider Demographics
NPI:1518350040
Name:VISRAV,LLC
Entity Type:Organization
Organization Name:VISRAV,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PRABHAV
Authorized Official - Middle Name:K
Authorized Official - Last Name:TELLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-607-9980
Mailing Address - Street 1:825 W ROYAL LN
Mailing Address - Street 2:SUITE 210
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-3601
Mailing Address - Country:US
Mailing Address - Phone:972-607-9980
Mailing Address - Fax:
Practice Address - Street 1:825 W ROYAL LN
Practice Address - Street 2:SUITE 210
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75039-3601
Practice Address - Country:US
Practice Address - Phone:972-607-9980
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-09
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D2090337291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory