Provider Demographics
NPI:1114246766
Name:MID ATLANTIC LABORATORY SERVICES, LLC
Entity Type:Organization
Organization Name:MID ATLANTIC LABORATORY SERVICES, LLC
Other - Org Name:MIDALABS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING DIRECTOR/PINCIPAL
Authorized Official - Prefix:MR
Authorized Official - First Name:ARDEN
Authorized Official - Middle Name:B
Authorized Official - Last Name:BOURGEOIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-334-1130
Mailing Address - Street 1:1610 FOREST AVE
Mailing Address - Street 2:SUITE 114
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23229-5009
Mailing Address - Country:US
Mailing Address - Phone:804-445-2940
Mailing Address - Fax:804-445-2930
Practice Address - Street 1:1610 FOREST AVE
Practice Address - Street 2:SUITE 114
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-5009
Practice Address - Country:US
Practice Address - Phone:804-445-2940
Practice Address - Fax:804-445-2930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-21
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory