1710282686 NPI number — ST MICHAELS LABS LAS VEGAS INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710282686 NPI number — ST MICHAELS LABS LAS VEGAS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST MICHAELS LABS LAS VEGAS INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710282686
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 924109
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77292-4109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-586-6778
Provider Business Mailing Address Fax Number:
713-586-6752

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2865 SIENA HEIGHTS DR
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89052-4167
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-824-9655
Provider Business Practice Location Address Fax Number:
702-889-4213
Provider Enumeration Date:
01/24/2011

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
JO ANN
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING ASSISITANT
Authorized Official Telephone Number:
713-586-6778

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  29D2008291 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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