Provider Demographics
NPI:1053850206
Name:BLUEWEST/LAB LLC
Entity Type:Organization
Organization Name:BLUEWEST/LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:RACHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS-BLUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-257-4339
Mailing Address - Street 1:1076 STAMPER RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-4191
Mailing Address - Country:US
Mailing Address - Phone:336-255-8285
Mailing Address - Fax:
Practice Address - Street 1:1076 STAMPER RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-4191
Practice Address - Country:US
Practice Address - Phone:336-255-8285
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34D2122291291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory