Provider Demographics
NPI:1679085781
Name:STAT LAB SOUTH LLC
Entity type:Organization
Organization Name:STAT LAB SOUTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHENETRA
Authorized Official - Middle Name:J
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:318-745-5227
Mailing Address - Street 1:681 PICKETTS MILL DRIVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115
Mailing Address - Country:US
Mailing Address - Phone:318-745-5227
Mailing Address - Fax:318-618-0298
Practice Address - Street 1:333 TEXAS AVE
Practice Address - Street 2:SUITE 1300
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71111
Practice Address - Country:US
Practice Address - Phone:318-618-0298
Practice Address - Fax:318-618-0298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN100044163W00000X
246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Single Specialty