Provider Demographics
NPI:1598755738
Name:SRINGLEAF MEDICAL, LTD
Entity Type:Organization
Organization Name:SRINGLEAF MEDICAL, LTD
Other - Org Name:AMERICAN WELLNESS LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-923-0012
Mailing Address - Street 1:PO BOX 20061
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77720-0061
Mailing Address - Country:US
Mailing Address - Phone:409-923-0012
Mailing Address - Fax:
Practice Address - Street 1:6310 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-7646
Practice Address - Country:US
Practice Address - Phone:409-923-0012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-27
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX167650401Medicaid
TXCL8568Medicare UPIN