Provider Demographics
NPI:1629594965
Name:SELECTMED DIAGNOSTICS, LLC
Entity Type:Organization
Organization Name:SELECTMED DIAGNOSTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:PRENTISS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:972-775-0835
Mailing Address - Street 1:2931 RIDGE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032-6684
Mailing Address - Country:US
Mailing Address - Phone:972-775-0835
Mailing Address - Fax:
Practice Address - Street 1:122 N INTERNATIONAL RD STE A
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75042-6530
Practice Address - Country:US
Practice Address - Phone:972-775-0835
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory