Provider Demographics
NPI:1831235795
Name:MEDICO CLINICAL LABORATORIES
Entity type:Organization
Organization Name:MEDICO CLINICAL LABORATORIES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LABORATORY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:LETICIA
Authorized Official - Middle Name:S
Authorized Official - Last Name:REYNA
Authorized Official - Suffix:
Authorized Official - Credentials:MT ASCP
Authorized Official - Phone:915-772-1768
Mailing Address - Street 1:4900 ALAMEDA AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-2832
Mailing Address - Country:US
Mailing Address - Phone:915-772-1768
Mailing Address - Fax:915-772-1768
Practice Address - Street 1:4900 ALAMEDA AVE
Practice Address - Street 2:SUITE E
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2832
Practice Address - Country:US
Practice Address - Phone:915-772-1768
Practice Address - Fax:915-772-1768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCL8361Medicare PIN
TXCL8361Medicare UPIN
TX1831235795Medicare PIN