1699778498 NPI number — FIRST LAB, LLC

Table of content: (NPI 1699778498)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699778498 NPI number — FIRST LAB, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIRST LAB, 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:
FIRST LAB
Provider Other Organization Name Type Code:
5
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:
1699778498
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1450
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORBIN
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40702-1450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-523-1274
Provider Business Mailing Address Fax Number:
606-528-3873

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2216 YOUNG DR
Provider Second Line Business Practice Location Address:
STE 2
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40505-4220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-335-0970
Provider Business Practice Location Address Fax Number:
606-528-3873
Provider Enumeration Date:
05/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
FORCHT
Authorized Official First Name:
TERRY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
606-528-9600

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  200259 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 37000510 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 800566 . This is a "BLACK LUNG" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000297502 . This is a "ANTHEM PROVIDER ID" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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