Provider Demographics
NPI:1104862606
Name:AURORA MEDICAL PARK LABORATORY LLC
Entity Type:Organization
Organization Name:AURORA MEDICAL PARK LABORATORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-335-2642
Mailing Address - Street 1:1451 44TH AVE S
Mailing Address - Street 2:UNIT D, SUITE H
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-3434
Mailing Address - Country:US
Mailing Address - Phone:701-335-2642
Mailing Address - Fax:701-787-8996
Practice Address - Street 1:1451 44TH AVE S
Practice Address - Street 2:UNIT D, SUITE H
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-3434
Practice Address - Country:US
Practice Address - Phone:701-335-2642
Practice Address - Fax:701-787-8996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory