Organization
BRAZOSPORT CLINICAL LAB
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. RICHARD A HARDOIN MD (PRESIDENT)
(979) 297-0362
Entity
Organization
Contact information
Practice address
54 FLAG LAKE PLZ, LAKE JACKSON, TX 77566-6263
(979) 297-0362
(979) 297-9096
Mailing address
54 FLAG LAKE PLZ, LAKE JACKSON, TX 77566-6263
(979) 297-0362
(979) 297-9096
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
Primary
45D0497096
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
45D0497096
CLIA
TX
Enumeration date
05/29/2008
Last updated
05/29/2008
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