1205983111 NPI number — FORENSIC TESTING SERVICES, LLC

Table of content: (NPI 1205983111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205983111 NPI number — FORENSIC TESTING SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FORENSIC TESTING SERVICES, 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:
CHILDREN'S MEDICAL SERVICES
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:
1205983111
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/18/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
630 N PRINCE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65802-6303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-882-9440
Provider Business Mailing Address Fax Number:
417-882-9441

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
630 N PRINCE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65802-6303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-882-9440
Provider Business Practice Location Address Fax Number:
417-882-9441
Provider Enumeration Date:
01/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BROEKHOVEN
Authorized Official First Name:
NATALIE
Authorized Official Middle Name:
D
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
417-882-9440

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  5385100001 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BX2000X , with the licence number: 5385100001 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 626310007 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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