Provider Demographics
NPI:1083157341
Name:MATRIX PATHOLOGY AND LABORATORY SERVICES PLLC
Entity Type:Organization
Organization Name:MATRIX PATHOLOGY AND LABORATORY SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WELDON
Authorized Official - Middle Name:
Authorized Official - Last Name:SANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:603-732-8656
Mailing Address - Street 1:4 HARVEST VW
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NH
Mailing Address - Zip Code:03031-3343
Mailing Address - Country:US
Mailing Address - Phone:603-732-8656
Mailing Address - Fax:
Practice Address - Street 1:100 MCGREGOR ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03102-3730
Practice Address - Country:US
Practice Address - Phone:603-663-8174
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-18
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH759903207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1225235302Medicare UPIN
1134161383Medicare PIN