1396321022 NPI number — SPECTRA LABORATORIES INC

Table of content: (NPI 1396321022)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396321022 NPI number — SPECTRA LABORATORIES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECTRA LABORATORIES INC
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:
1396321022
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/25/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1280 STATELINE RD E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHAVEN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38671-9486
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-334-0021
Provider Business Mailing Address Fax Number:
800-716-5539

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1280 STATELINE RD E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHAVEN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38671-9486
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-334-0021
Provider Business Practice Location Address Fax Number:
800-716-5539
Provider Enumeration Date:
03/23/2021

Additional Information

Authorized Official

Authorized Official Last Name:
RYDER
Authorized Official First Name:
ALEX
Authorized Official Middle Name:
Authorized Official Title or Position:
SENIOR VP AND MEDICAL DIRECTOR
Authorized Official Telephone Number:
877-334-0021

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: 003263868A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08652003 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1396321022 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1396321022 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 649049-OC , issued by the state of ( AS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 97820288 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: L00865 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 013403892 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 112006800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100777440 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: Q069018 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100245690C , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1396321022 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1396321022 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1396321022 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1396321022 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2574035 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6709267 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9000198819 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10026890900 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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