1669431649 NPI number — MID AMERICA CLINICAL LABORATORIES, LLC

Table of content: (NPI 1669431649)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669431649 NPI number — MID AMERICA CLINICAL LABORATORIES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID AMERICA CLINICAL LABORATORIES, 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:
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:
1669431649
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:
2560 N SHADELAND AVE
Provider Second Line Business Mailing Address:
P.O. BOX 19163
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46219-1705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-803-1010
Provider Business Mailing Address Fax Number:
317-803-0186

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1345 UNITY PL
Provider Second Line Business Practice Location Address:
SUITE 125
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47905-5760
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-449-1848
Provider Business Practice Location Address Fax Number:
765-449-8127
Provider Enumeration Date:
03/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KMETZ
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
317-803-1010

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  15D0995210 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 15D0995210 . This is a "CLIA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 7177548 . This is a "CAP" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200188040B , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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