Cedar Creek Labs LLC

Primary specialty

Clinical Medical LaboratoryTaxonomy code 291U00000X

License

45D2010541 Issued in TX

Legal business name

CEDAR CREEK LABS LLC

Practice address

4200 Burch Dr Ste C9
Del Valle, TX 78617-3234

Phone

(511) 714-9996

Fax

(888) 793-0432

NPI assigned

Nov 10, 2016

Organization subpart

No

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

Authorized official

Name

Ty Bruggeman

Title

Owner

Phone

(281) 714-9996

Specialties & licenses 1

Addresses

Other identifiers 1

Locations

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

{
    "created_epoch": "1478736000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1478736000000",
    "number": "1407398241",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4200 BURCH DR STE C9",
            "city": "DEL VALLE",
            "state": "TX",
            "postal_code": "786173234",
            "telephone_number": "511-714-9996",
            "fax_number": "888-793-0432"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4200 BURCH DR STE C9",
            "city": "DEL VALLE",
            "state": "TX",
            "postal_code": "786173234",
            "telephone_number": "511-714-9996",
            "fax_number": "888-793-0432"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CEDAR CREEK LABS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-11-10",
        "last_updated": "2016-11-10",
        "status": "A",
        "authorized_official_last_name": "BRUGGEMAN",
        "authorized_official_first_name": "TY",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "281-714-9996"
    },
    "taxonomies": [
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": "TX",
            "license": "45D2010541",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CLIA",
            "identifier": "45D2010541",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Alexandra Brace, CPM, LM
• Deryl Brown, PMHNP
• Patrice Patton Budd, PNP
• Tiffany Carlson, LMHC, LPC
• Shana Casey, MSN, RN, PMHNP-BC
• Central Texas Community Health Centers
• Central Texas Community Health Centers
• Curefast Medical del Valle PLLC
• CVS Pharmacy, Inc.
• Del Valle Isd

• Clinical Medical Laboratory in Del Valle, TX
• Providers in Del Valle, 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 Nov 10, 2016; 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.