Provider Demographics
NPI:1801542824
Name:PRIVY DIAGNOSTICS LABS, LLC
Entity type:Organization
Organization Name:PRIVY DIAGNOSTICS LABS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TAAKA
Authorized Official - Middle Name:
Authorized Official - Last Name:CASH
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, PMHMP-BC
Authorized Official - Phone:833-667-7924
Mailing Address - Street 1:1230 N KIMBALL AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-4707
Mailing Address - Country:US
Mailing Address - Phone:833-667-7924
Mailing Address - Fax:
Practice Address - Street 1:3224 GUS THOMASSON RD STE B
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-4004
Practice Address - Country:US
Practice Address - Phone:833-667-7924
Practice Address - Fax:817-755-0945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physicianGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Multi-Specialty
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No305S00000XManaged Care OrganizationsPoint of ServiceGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1114264199OtherINDIVIDUAL NPI
TX336552Medicaid