Provider Demographics
NPI:1174925382
Name:ELL PATHOLOGY LAB, LLC
Entity type:Organization
Organization Name:ELL PATHOLOGY LAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER & DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:D
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-604-2695
Mailing Address - Street 1:10810 EXECUTIVE CENTER DR STE 101
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4386
Mailing Address - Country:US
Mailing Address - Phone:501-604-2695
Mailing Address - Fax:501-604-2699
Practice Address - Street 1:10810 EXECUTIVE CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-4386
Practice Address - Country:US
Practice Address - Phone:501-604-2695
Practice Address - Fax:501-604-2699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-18
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR04D2068199OtherCLIA
ARLAP80759OtherNYSDOH CLINICAL LABORATORY PERMIT