Provider Demographics
NPI:1669984183
Name:ILES MEDICAL TESTING,LLC
Entity type:Organization
Organization Name:ILES MEDICAL TESTING,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ILES
Authorized Official - Suffix:
Authorized Official - Credentials:LA,CPT,MROA
Authorized Official - Phone:337-562-0835
Mailing Address - Street 1:3437 DEREK DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70607-7533
Mailing Address - Country:US
Mailing Address - Phone:337-562-0835
Mailing Address - Fax:337-562-8985
Practice Address - Street 1:3437 DEREK DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-7533
Practice Address - Country:US
Practice Address - Phone:337-562-0835
Practice Address - Fax:337-562-8985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-25
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1669984183Medicaid