Provider Demographics
NPI:1760482665
Name:PRIVIA MEDICAL GROUP WEST TEXAS, PLLC
Entity Type:Organization
Organization Name:PRIVIA MEDICAL GROUP WEST TEXAS, PLLC
Other - Org Name:WEST TEXAS HEALTH LABORATORY
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:KOUBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-437-8645
Mailing Address - Street 1:PO BOX 5409
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79608-5409
Mailing Address - Country:US
Mailing Address - Phone:325-437-8655
Mailing Address - Fax:325-437-8647
Practice Address - Street 1:1665 ANTILLEY RD STE 190
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606-5249
Practice Address - Country:US
Practice Address - Phone:325-793-5158
Practice Address - Fax:325-793-5192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-21
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246Q00000X
TX45D0907638246Q00000X
TX45D0978789246Q00000X
TX45D0964533246Q00000X
TX45D0949404246Q00000X
TX45D0508504246Q00000X
TX45D0889919246Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246Q00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCL0703Medicare PIN
TXCL0703Medicare ID - Type UnspecifiedLAB SERVICES