Provider Demographics
NPI:1093121188
Name:LAKS, MITCHELL
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:LAKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2240
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27216-2240
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2250 W CAMPBELL PARK DR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3502
Practice Address - Country:US
Practice Address - Phone:312-243-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QL0901XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyLaboratory Management, Diplomate
Provider Identifiers
StateIdentifier IDID TypeIssuer
14D0897314OtherCLIA