1831167196 NPI number — LAB OF PATH, PA

Table of content: (NPI 1831167196)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831167196 NPI number — LAB OF PATH, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAB OF PATH, PA
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:
1831167196
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1915 W BEEBE CAPPS EXPY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEARCY
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72143-5012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-268-8175
Provider Business Mailing Address Fax Number:
501-268-8337

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1915 W BEEBE CAPPS EXPY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEARCY
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72143-5012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-268-8175
Provider Business Practice Location Address Fax Number:
501-268-8337
Provider Enumeration Date:
03/10/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GOLLEHER
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
HENRY
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
501-268-8175

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  MC0253 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0102X , with the licence number: MC0253 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 770046609 . This is a "BREASTCARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 106515709 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2022102 . This is a "CAP" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: MC0253 . This is a "STATE LICENSE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 04D0891911 . This is a "CLIA" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 770093602 . This is a "BREASTCARE OTHER" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".