1619972254 NPI number — COMPUNET CLINICAL LABORATORIES LLC

Table of content: (NPI 1619972254)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619972254 NPI number — COMPUNET CLINICAL LABORATORIES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMPUNET CLINICAL 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:
COMPUNET CLINICAL LABORTORIES LTD
Provider Other Organization Name Type Code:
4
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:
1619972254
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2308 SANDRIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORAINE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45439-1847
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-296-0844
Provider Business Mailing Address Fax Number:
937-297-8232

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2308 SANDRIDGE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORAINE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45439-1847
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-296-0844
Provider Business Practice Location Address Fax Number:
937-297-8232
Provider Enumeration Date:
06/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
TERESA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
937-297-8228

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  36D0350049 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0654619 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000013050 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0658515 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 690002971 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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