Provider Demographics
NPI:1992314306
Name:PROLAB INCORPORATED
Entity type:Organization
Organization Name:PROLAB INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:SAUL
Authorized Official - Last Name:PORTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-430-8078
Mailing Address - Street 1:PRO-LAB DIAGNOSTICS
Mailing Address - Street 2:1301 BLUE RIDGE DRIVE SUITE 101
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-1034
Mailing Address - Country:US
Mailing Address - Phone:512-832-9145
Mailing Address - Fax:
Practice Address - Street 1:PRO-LAB DIAGNOSTICS US
Practice Address - Street 2:21 CYPRESS BLVD. STE. 1155
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665
Practice Address - Country:US
Practice Address - Phone:512-832-9145
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-31
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory