Provider Demographics
NPI:1306143607
Name:MOLECULAR MEDICAL LABORATORY, INC
Entity type:Organization
Organization Name:MOLECULAR MEDICAL LABORATORY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BERTHA
Authorized Official - Middle Name:ALICIA
Authorized Official - Last Name:CARDONA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-581-0700
Mailing Address - Street 1:2218 W MILE 5 RD
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78574-4935
Mailing Address - Country:US
Mailing Address - Phone:956-581-0700
Mailing Address - Fax:956-581-0701
Practice Address - Street 1:2218 W MILE 5 RD
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78574-4935
Practice Address - Country:US
Practice Address - Phone:956-581-0700
Practice Address - Fax:956-581-0701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-22
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D2020075291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCL1160Medicare PIN