Provider Demographics
NPI:1942766597
Name:MB DIAGNOSTIC LABS EASTERN COMMUNITY LABS
Entity Type:Organization
Organization Name:MB DIAGNOSTIC LABS EASTERN COMMUNITY LABS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAKE
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:WEXLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-841-3509
Mailing Address - Street 1:2408 TIMBERLOCH PL STE B1
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77380-1060
Mailing Address - Country:US
Mailing Address - Phone:877-841-3509
Mailing Address - Fax:864-453-3004
Practice Address - Street 1:2408 TIMBERLOCH PL STE B1
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-1060
Practice Address - Country:US
Practice Address - Phone:877-841-3509
Practice Address - Fax:864-453-3004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-19
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory