1801390521 NPI number — LOCAL LAB LLC

Table of content: (NPI 1801390521)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801390521 NPI number — LOCAL LAB LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOCAL 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:
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:
1801390521
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8382 N WAYNE DR STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAYDEN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83835-6028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-714-0478
Provider Business Mailing Address Fax Number:
855-485-5234

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8382 N WAYNE DR STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAYDEN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83835-6028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-714-0478
Provider Business Practice Location Address Fax Number:
855-485-5234
Provider Enumeration Date:
03/19/2018

Additional Information

Authorized Official

Authorized Official Last Name:
SAMORA
Authorized Official First Name:
MORGANA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
208-929-2234

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  13 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 13D2141188 . This is a "CLIA ID" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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