1194903013 NPI number — DIAGNOSTIC LABORATORY OF OKLAHOMA LLC

Table of content: (NPI 1194903013)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194903013 NPI number — DIAGNOSTIC LABORATORY OF OKLAHOMA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIAGNOSTIC LABORATORY OF OKLAHOMA LLC
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:
INTEGRIS BASS BAPTIST HEALTH CENTER
Provider Other Organization Name Type Code:
5
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:
1194903013
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1201 S COLLEGEVILLE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLLEGEVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19426-2998
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-697-8378
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 S MONROE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENID
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73701-7211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-548-1185
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/01/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SELL
Authorized Official First Name:
LEO
Authorized Official Middle Name:
Authorized Official Title or Position:
CONTROLLER
Authorized Official Telephone Number:
405-608-6298

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  37D0472533 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 37D0472533 , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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