Provider Demographics
NPI:1972829513
Name:LAKERIDGE LABORATORY INC
Entity Type:Organization
Organization Name:LAKERIDGE LABORATORY INC
Other - Org Name:LAKERIDGE LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:512-913-6512
Mailing Address - Street 1:1712 E RIVERSIDE DR
Mailing Address - Street 2:STE 232
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78741-1320
Mailing Address - Country:US
Mailing Address - Phone:512-913-6512
Mailing Address - Fax:
Practice Address - Street 1:5130 82ND ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-3024
Practice Address - Country:US
Practice Address - Phone:512-913-6512
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-07
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D0678293291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory