Provider Demographics
NPI:1114227246
Name:SPECIALTY LABS PLLC
Entity Type:Organization
Organization Name:SPECIALTY LABS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LAB DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-939-3505
Mailing Address - Street 1:951 E PLAZA DR
Mailing Address - Street 2:SUITE 170
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616
Mailing Address - Country:US
Mailing Address - Phone:208-939-3505
Mailing Address - Fax:939-939-3507
Practice Address - Street 1:951 E PLAZA DR
Practice Address - Street 2:SUITE 170
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616
Practice Address - Country:US
Practice Address - Phone:208-939-3505
Practice Address - Fax:939-939-3507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-22
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory