1669451977 NPI number — HEALTH VENTURES OF SOUTHERN ILLONOIS LLC

Table of content: (NPI 1669451977)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669451977 NPI number — HEALTH VENTURES OF SOUTHERN ILLONOIS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTH VENTURES OF SOUTHERN ILLONOIS 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:
TRI-LAB LLC
Provider Other Organization Name Type Code:
3
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:
1669451977
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 790051
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63179-0051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-343-0640
Provider Business Mailing Address Fax Number:
618-343-0684

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
180 S 3RD ST
Provider Second Line Business Practice Location Address:
STE 300 TRI-LAB LLC @ ST ELIZABETH'S MEDICAL ARTS BUILD
Provider Business Practice Location Address City Name:
BELLEVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62220-1952
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-233-4187
Provider Business Practice Location Address Fax Number:
618-239-0914
Provider Enumeration Date:
01/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HUGHES
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
618-343-0639

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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