1164420568 NPI number — CD LABORATORIES, INC.

Table of content: (NPI 1164420568)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164420568 NPI number — CD LABORATORIES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CD LABORATORIES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164420568
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
810 GLENEAGLES CT STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21286-2231
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-296-1400
Provider Business Mailing Address Fax Number:
410-296-0081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
810 GLENEAGLES CT STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21286-2231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-296-1400
Provider Business Practice Location Address Fax Number:
410-296-0081
Provider Enumeration Date:
07/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ROOK
Authorized Official First Name:
TAMARA
Authorized Official Middle Name:
Authorized Official Title or Position:
VP, GLOBAL MARKET ACCESS
Authorized Official Telephone Number:
303-518-7069

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  204 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0118869 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 021732500 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201288030A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 102738 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008058044 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00534551 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: W212 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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