Organization
PRODIGY TOXICOLOGY LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KIM SIVARAMAN (BILLING MANAGER)
(214) 618-5600
Entity
Organization
Contact information
Practice address
3861 LONG PRAIRIE RD STE 109, FLOWER MOUND, TX 75028-1799
(214) 513-8700
(214) 513-8730
Mailing address
5566 MAIN ST STE 210, FRISCO, TX 75033-3673
(214) 618-5600
(214) 618-7733
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
Primary
45D2084574
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
45D2084574
CLIA
TX
Enumeration date
10/08/2014
Last updated
10/21/2014
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