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:
07/31/2023
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:
CHURCHILL
Authorized Official First Name:
CHRIS
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
781-699-2306

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: 08652003 , issued by the state of ( MS ) . 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 ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1396321022 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1396321022 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1396321022 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 273863709 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4092925 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0468700 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1396321022 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1396321022 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1396321022 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 112006800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1396321022 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2203364 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2574035 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 440392501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 649049-OC , issued by the state of ( AS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6709267 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100777440 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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