Provider Demographics
NPI:1003187741
Name:SOUTHERN LABORATORIES LLC
Entity Type:Organization
Organization Name:SOUTHERN LABORATORIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:CELESTINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-515-7016
Mailing Address - Street 1:PO BOX 381
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70602-0381
Mailing Address - Country:US
Mailing Address - Phone:337-515-7061
Mailing Address - Fax:
Practice Address - Street 1:2106 ENTERPRISE BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-7666
Practice Address - Country:US
Practice Address - Phone:337-515-7016
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory