Provider Demographics
NPI:1033519020
Name:AMERICAN MEDICAL LAB INC
Entity type:Organization
Organization Name:AMERICAN MEDICAL LAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:
Authorized Official - Last Name:ITAMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-677-8401
Mailing Address - Street 1:755 S 11TH ST
Mailing Address - Street 2:SUITE 255
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77701-3732
Mailing Address - Country:US
Mailing Address - Phone:409-356-6008
Mailing Address - Fax:409-833-1909
Practice Address - Street 1:755 S 11TH ST
Practice Address - Street 2:SUITE 255
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-3732
Practice Address - Country:US
Practice Address - Phone:409-356-6008
Practice Address - Fax:409-833-1909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-27
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D2057150291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45D2057150OtherCLIA