Provider Demographics
NPI:1669079208
Name:EXOVA DIAGNOSTICS LLC
Entity type:Organization
Organization Name:EXOVA DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-471-5360
Mailing Address - Street 1:11331 JAMES WATT DR STE 300A
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-6401
Mailing Address - Country:US
Mailing Address - Phone:503-464-6467
Mailing Address - Fax:805-591-4810
Practice Address - Street 1:11331 JAMES WATT DR STE 300A
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-6401
Practice Address - Country:US
Practice Address - Phone:503-464-6467
Practice Address - Fax:805-591-4810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-07
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45D2194972OtherCLIA