Provider Demographics
NPI:1285951665
Name:PROFESSIONAL CLINICAL LABORATORY INC
Entity type:Organization
Organization Name:PROFESSIONAL CLINICAL LABORATORY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT-COO
Authorized Official - Prefix:MRS
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:BS, MT,ASCP
Authorized Official - Phone:866-776-5221
Mailing Address - Street 1:3020 WICHITA CT
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76140-1710
Mailing Address - Country:US
Mailing Address - Phone:866-776-5221
Mailing Address - Fax:817-568-1960
Practice Address - Street 1:234 AQUARIUS DR
Practice Address - Street 2:SUITE 122
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35209-5872
Practice Address - Country:US
Practice Address - Phone:866-776-2221
Practice Address - Fax:817-568-1960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-26
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1523402Medicaid
690008760OtherRAILROAD MEDICARE
P00377680OtherRAILROAD MEDICARE
P00377679OtherRAILROAD MEDICARE
TX025542401Medicaid
AR164542709Medicaid
AL690000082Medicaid
TXCL5046OtherBLUE CROSS BLUE SHIELD
OK200094750AMedicaid
MS06408362Medicaid
TX160698001Medicaid
AL690000082Medicaid
MS690000082Medicare PIN
TXCL8392Medicare PIN
OK200094750AMedicaid
TX025542401Medicaid
MS06408362Medicaid
TXCL8596Medicare PIN