Provider Demographics
NPI:1003908526
Name:FAMILY MEDICAL LAB, INC.
Entity Type:Organization
Organization Name:FAMILY MEDICAL LAB, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LOUCKS
Authorized Official - Suffix:
Authorized Official - Credentials:MT(ASCP),MA
Authorized Official - Phone:580-233-2909
Mailing Address - Street 1:915 E OWEN K GARRIOTT RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-6156
Mailing Address - Country:US
Mailing Address - Phone:580-233-2909
Mailing Address - Fax:580-233-2937
Practice Address - Street 1:915 E OWEN K GARRIOTT RD
Practice Address - Street 2:SUITE E
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-6156
Practice Address - Country:US
Practice Address - Phone:580-233-2909
Practice Address - Fax:580-233-2937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK37D0472553291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK690120393OtherPALMETO GBA RR MEDICARE
OK100758450AMedicaid
OK100758450AMedicaid
OK100758450AMedicaid