Provider Demographics
NPI:1396957221
Name:PEGASUS PRECISION LABORATORIES,LLC
Entity type:Organization
Organization Name:PEGASUS PRECISION LABORATORIES,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-906-2121
Mailing Address - Street 1:5833 SPOHN DR
Mailing Address - Street 2:SUITE 805
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78414-4135
Mailing Address - Country:US
Mailing Address - Phone:361-906-2121
Mailing Address - Fax:361-906-2103
Practice Address - Street 1:5833 SPOHN DR
Practice Address - Street 2:SUITE 805
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78414-4135
Practice Address - Country:US
Practice Address - Phone:361-906-2121
Practice Address - Fax:361-906-2103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1073627071Medicaid
TX1861401739Medicaid
TX8F3861Medicare ID - Type UnspecifiedPROVIDER NUMBER
TX1073627071Medicaid