Provider Demographics
NPI:1538157086
Name:PATHOLOGY REFERENCE LABORATORY, L.L.C.
Entity type:Organization
Organization Name:PATHOLOGY REFERENCE LABORATORY, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:RUPNOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-892-3707
Mailing Address - Street 1:PO BOX 2037
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78297-2037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9600 DATAPOINT DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-2028
Practice Address - Country:US
Practice Address - Phone:210-892-3700
Practice Address - Fax:210-614-4659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-10
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D0974323291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CL5070OtherBLUE CROSS BLUE SHIELD
TXL0DL84554Medicaid
TX45D0974323OtherCLIA
TXCL8455Medicare ID - Type Unspecified