Provider Demographics
NPI:1043936297
Name:DISTINCTIVE DIAGNOSTICS LABORATORY
Entity Type:Organization
Organization Name:DISTINCTIVE DIAGNOSTICS LABORATORY
Other - Org Name:DISTINCTIVE DIAGNOSTICS LABORATORY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:STACI
Authorized Official - Middle Name:
Authorized Official - Last Name:BEASLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-881-0575
Mailing Address - Street 1:1301 YORK RD FL 8
Mailing Address - Street 2:
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-6035
Mailing Address - Country:US
Mailing Address - Phone:800-410-9508
Mailing Address - Fax:
Practice Address - Street 1:1301 YORK RD STE 800
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-6011
Practice Address - Country:US
Practice Address - Phone:800-410-9508
Practice Address - Fax:800-410-9508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-18
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory