Provider Demographics
NPI:1578549051
Name:ELITE LAB SERVICES LLC
Entity Type:Organization
Organization Name:ELITE LAB SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:DENGLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-509-3522
Mailing Address - Street 1:2211 ROY ROAD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75707-6275
Mailing Address - Country:US
Mailing Address - Phone:903-509-3522
Mailing Address - Fax:903-509-3523
Practice Address - Street 1:2211 ROY ROAD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75707-6275
Practice Address - Country:US
Practice Address - Phone:903-509-3522
Practice Address - Fax:903-509-3523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-16
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D1044325291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176690901Medicaid
TX176690901Medicaid