Provider Demographics
NPI:1073100582
Name:COAL MOUNTAIN LABORATORY
Entity Type:Organization
Organization Name:COAL MOUNTAIN LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NICK
Authorized Official - Middle Name:
Authorized Official - Last Name:PFEIFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-235-5795
Mailing Address - Street 1:10928 WORTHINGTON LN
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-9590
Mailing Address - Country:US
Mailing Address - Phone:502-235-5795
Mailing Address - Fax:
Practice Address - Street 1:5321 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2221
Practice Address - Country:US
Practice Address - Phone:502-235-5795
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-30
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory