1780160770 NPI number — GULF COAST MOLECULAR LABORATORIES, LLC

Table of content: (NPI 1780160770)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780160770 NPI number — GULF COAST MOLECULAR LABORATORIES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GULF COAST MOLECULAR 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:
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:
1780160770
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11617 HWY 31
Provider Second Line Business Mailing Address:
UNIT 3
Provider Business Mailing Address City Name:
SPANISH FORT
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-494-2540
Provider Business Mailing Address Fax Number:
251-930-6727

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11617 HWY 31
Provider Second Line Business Practice Location Address:
UNIT 3
Provider Business Practice Location Address City Name:
SPANISH FORT
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-494-2540
Provider Business Practice Location Address Fax Number:
205-374-8606
Provider Enumeration Date:
07/13/2018

Additional Information

Authorized Official

Authorized Official Last Name:
POTTER
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
251-494-2540

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: 227036 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 427926701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 104860600 . 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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