Provider Demographics
NPI:1629613922
Name:SPACE CITY LABORATORIES
Entity Type:Organization
Organization Name:SPACE CITY LABORATORIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:USMAN
Authorized Official - Last Name:AIJAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-235-5842
Mailing Address - Street 1:PO BOX 2045
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77487-2045
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16753 DONWICK DR STE A6
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77385-3675
Practice Address - Country:US
Practice Address - Phone:281-235-5842
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-10
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory