Provider Demographics
NPI:1053723171
Name:SOUTHLAKE DIAGNOSTICS INC
Entity type:Organization
Organization Name:SOUTHLAKE DIAGNOSTICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DON
Authorized Official - Middle Name:
Authorized Official - Last Name:STABLES
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:617-538-1748
Mailing Address - Street 1:580 COMMERCE ST STE 150B
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-9214
Mailing Address - Country:US
Mailing Address - Phone:817-421-7414
Mailing Address - Fax:
Practice Address - Street 1:580 COMMERCE ST
Practice Address - Street 2:SUITE 150
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-9155
Practice Address - Country:US
Practice Address - Phone:817-421-7414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-23
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory