Provider Demographics
NPI:1033285044
Name:TRICORE REFERENCE LABORATORIES
Entity Type:Organization
Organization Name:TRICORE REFERENCE LABORATORIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CROSSEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-938-8888
Mailing Address - Street 1:1001 WOODWARD PL NE
Mailing Address - Street 2:ATTENTION: BUSINESS OFFICE
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2705
Mailing Address - Country:US
Mailing Address - Phone:505-938-8888
Mailing Address - Fax:505-938-8833
Practice Address - Street 1:1001 WOODWARD PL NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2705
Practice Address - Country:US
Practice Address - Phone:505-938-8888
Practice Address - Fax:505-938-8833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV004388300Medicaid
ME191050000Medicaid
ID806981000Medicaid
CO98003643Medicaid
WY119530100Medicaid
OK200049370AMedicaid
TX073041801Medicaid
NM000L0628Medicaid
AZ627375Medicaid
690008077OtherRAILROAD MEDICARE
OK200049370AMedicaid