Provider Demographics
NPI:1972970978
Name:CRESTAR LABS LLC
Entity Type:Organization
Organization Name:CRESTAR LABS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:FADEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ALSHALABI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-433-8888
Mailing Address - Street 1:1651 N COLLINS BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-3658
Mailing Address - Country:US
Mailing Address - Phone:469-530-9050
Mailing Address - Fax:469-530-9051
Practice Address - Street 1:1651 N COLLINS BLVD STE 130
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-3658
Practice Address - Country:US
Practice Address - Phone:469-530-9050
Practice Address - Fax:469-530-9051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-25
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D2098649291U00000X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3672776-01Medicaid