Provider Demographics
NPI:1932576931
Name:FORTIS LABS LLC
Entity Type:Organization
Organization Name:FORTIS LABS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO/CCO
Authorized Official - Prefix:MR
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:MANIPOL
Authorized Official - Suffix:
Authorized Official - Credentials:MLS, ASCP
Authorized Official - Phone:310-975-4797
Mailing Address - Street 1:1651 N COLLINS BLVD STE 135
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-3658
Mailing Address - Country:US
Mailing Address - Phone:469-530-9050
Mailing Address - Fax:469-530-9051
Practice Address - Street 1:1651 N COLLINS BLVD STE 135
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-3658
Practice Address - Country:US
Practice Address - Phone:469-530-9050
Practice Address - Fax:469-530-9051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-25
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D2098646291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory