Provider Demographics
NPI:1063831121
Name:HIGH DESERT DIAGNOSTIC LABORATORY
Entity Type:Organization
Organization Name:HIGH DESERT DIAGNOSTIC LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:FELLOWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-713-1290
Mailing Address - Street 1:1003 DIVISION ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1657
Mailing Address - Country:US
Mailing Address - Phone:928-445-0103
Mailing Address - Fax:928-445-1032
Practice Address - Street 1:1003 DIVISION ST
Practice Address - Street 2:SUITE 5
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1657
Practice Address - Country:US
Practice Address - Phone:928-445-0103
Practice Address - Fax:928-445-1032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ03D2075971291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory