1093879140 NPI number — DCL MEDICAL LABORATORIES, LLC

Table of content: (NPI 1093879140)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093879140 NPI number — DCL MEDICAL LABORATORIES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DCL MEDICAL 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:
1093879140
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9550 ZIONSVILLE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46268-1065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-874-1319
Provider Business Mailing Address Fax Number:
317-874-1440

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1616 EAST PORT PLAZA
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLLINSVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62234
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-343-0002
Provider Business Practice Location Address Fax Number:
317-874-1440
Provider Enumeration Date:
12/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BUCHER
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
A
Authorized Official Title or Position:
VP OF FINANCE
Authorized Official Telephone Number:
317-874-1297

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: 100237800 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 351609041002 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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