Provider Demographics
NPI:1881097509
Name:PRODIGY TOXICOLOGY LLC
Entity type:Organization
Organization Name:PRODIGY TOXICOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:SIVARAMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-618-5600
Mailing Address - Street 1:5566 MAIN ST STE 210
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-3673
Mailing Address - Country:US
Mailing Address - Phone:214-618-5600
Mailing Address - Fax:214-618-7733
Practice Address - Street 1:3861 LONG PRAIRIE RD STE 109
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-1799
Practice Address - Country:US
Practice Address - Phone:214-513-8700
Practice Address - Fax:214-513-8730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-08
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D2084574291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45D2084574OtherCLIA