1508275082 NPI number — INDUSTRY LAB DIAGNOSTIC PARTNERS LLC

Table of content: (NPI 1508275082)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508275082 NPI number — INDUSTRY LAB DIAGNOSTIC PARTNERS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDUSTRY LAB DIAGNOSTIC PARTNERS 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:
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:
1508275082
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9363 ALLEN RD STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST CHESTER
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45069-3846
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-866-7922
Provider Business Mailing Address Fax Number:
513-860-0373

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
INDUSTRY LAB DIAGNOSTIC PARTNERS
Provider Second Line Business Practice Location Address:
9363 ALLEN RD STE B
Provider Business Practice Location Address City Name:
WEST CHESTER
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45069
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-866-7922
Provider Business Practice Location Address Fax Number:
513-860-0373
Provider Enumeration Date:
08/08/2014

Additional Information

Authorized Official

Authorized Official Last Name:
EVANS
Authorized Official First Name:
TROY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRINCIPAL
Authorized Official Telephone Number:
513-866-7922

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  44D2080450 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ========= . This is a "EIN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 36D2180180 . This is a "CLIA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 015062100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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