1164710893 NPI number — LABTRAN CLINICAL LABORATORIES, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164710893 NPI number — LABTRAN CLINICAL LABORATORIES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LABTRAN 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:
6
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:
1164710893
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
04/03/2013
NPI Reactivation Date:
04/10/2013

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
106 WESTHILL DRIVE, UNIT D.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEBANON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37087
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-522-8726
Provider Business Mailing Address Fax Number:
888-581-0336

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2404 E MILL PLAIN BLVD STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98661-4334
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-522-8726
Provider Business Practice Location Address Fax Number:
888-581-0336
Provider Enumeration Date:
07/15/2011

Additional Information

Authorized Official

Authorized Official Last Name:
LAFURGE
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
CEO/CFO
Authorized Official Telephone Number:
360-852-0302

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)

  • Identifier: 44D2028000 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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