Provider Demographics
NPI:1902931207
Name:STAT DIAGNOSTIC LAB LLC
Entity Type:Organization
Organization Name:STAT DIAGNOSTIC LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DELIA
Authorized Official - Middle Name:DELORES
Authorized Official - Last Name:BOOKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-434-4032
Mailing Address - Street 1:4515 COLONIAL AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75215-4140
Mailing Address - Country:US
Mailing Address - Phone:214-434-4032
Mailing Address - Fax:
Practice Address - Street 1:509 N HAMPTON RD
Practice Address - Street 2:SUITE 204
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-4970
Practice Address - Country:US
Practice Address - Phone:972-230-2323
Practice Address - Fax:972-230-2324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD20449OtherCLIA
TX45D1064567OtherCLIA