Professional Clinical Laboratory, Inc

Primary specialty

Clinical Medical LaboratoryTaxonomy code 291U00000X

License

36D2050322 Issued in OH

Legal business name

PROFESSIONAL CLINICAL LABORATORY, INC

Practice address

3020 Wichita CT
Ft Worth, TX 76140-1710

Phone

(866) 776-5221

Fax

(682) 647-6238

NPI assigned

Mar 4, 2013

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mrs. Holly Renea Shields

Title

Coo/Vice President

Phone

(866) 776-5221

Specialties & licenses 1

Addresses

Other identifiers 10

Other names 1

• ProLab Doing business as

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1362355200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1362355200000",
    "number": "1255672176",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6660 DOUBLETREE AVE",
            "city": "COLUMBUS",
            "state": "OH",
            "postal_code": "432291128",
            "telephone_number": "866-776-5221",
            "fax_number": "682-647-6238"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3020 WICHITA CT",
            "city": "FT WORTH",
            "state": "TX",
            "postal_code": "761401710",
            "telephone_number": "866-776-5221",
            "fax_number": "682-647-6238"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROFESSIONAL CLINICAL LABORATORY, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-03-04",
        "last_updated": "2013-03-04",
        "status": "A",
        "authorized_official_last_name": "SHIELDS",
        "authorized_official_first_name": "HOLLY",
        "authorized_official_middle_name": "RENEA",
        "authorized_official_title_or_position": "COO/VICE PRESIDENT",
        "authorized_official_telephone_number": "866-776-5221",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": "OH",
            "license": "36D2050322",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "286063701",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200094750A",
            "state": "OK"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "191954001",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1523402",
            "state": "LA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "140312",
            "state": "AL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "164542709",
            "state": "AR"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUESHIELD",
            "identifier": "CL5046",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00054521",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "160698001",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "690008760",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ProLab",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Clinical Medical Laboratory in Ft Worth, TX
• Providers in Ft Worth, TX by specialty
• Clinical Medical Laboratory in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 4, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.