1174384358 NPI number — TEST LABORATORY LLC

Table of content: (NPI 1174384358)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174384358 NPI number — TEST LABORATORY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TEST LABORATORY 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:
TE LABS
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:
1174384358
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1499 LYNWOOD DR STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANCASTER
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29720-0964
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-286-7157
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1499 LYNWOOD DR STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANCASTER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29720-0964
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-286-7157
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/16/2024

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MUNGO-BROWN
Authorized Official First Name:
PORSHA
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL DIRECTOR
Authorized Official Telephone Number:
803-286-7157

Provider Taxonomy Codes

  • Taxonomy code: 246QH0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 246QL0900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 246RM2200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 246RP1900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 343900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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