Provider Demographics
NPI:1003802075
Name:BRADSHAW MOUNTAIN DIAGNOSTIC LABORATORY INC.
Entity Type:Organization
Organization Name:BRADSHAW MOUNTAIN DIAGNOSTIC LABORATORY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:FELLOWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-778-7823
Mailing Address - Street 1:990 WILLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1640
Mailing Address - Country:US
Mailing Address - Phone:928-778-7823
Mailing Address - Fax:928-778-9419
Practice Address - Street 1:990 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1640
Practice Address - Country:US
Practice Address - Phone:928-778-7823
Practice Address - Fax:928-778-9419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ050576Medicaid
AZ050576Medicaid