Provider Demographics
NPI:1689693830
Name:EAST TEXAS CARDIOVASCULAR LABS, LLC
Entity Type:Organization
Organization Name:EAST TEXAS CARDIOVASCULAR LABS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PRABHAKAR
Authorized Official - Middle Name:R
Authorized Official - Last Name:GUNIGANTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-560-1844
Mailing Address - Street 1:1303 N MOUND ST
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-4030
Mailing Address - Country:US
Mailing Address - Phone:936-560-1844
Mailing Address - Fax:936-715-9135
Practice Address - Street 1:1303 N MOUND ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4030
Practice Address - Country:US
Practice Address - Phone:936-560-1844
Practice Address - Fax:936-715-9135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008031261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXHH1807OtherBLUE CROSS PROVIDER #
TX034329502Medicaid
TXHH1807OtherBLUE CROSS PROVIDER #
TX034329502Medicaid