Provider Demographics
NPI:1114329109
Name:INDEPENDENT LAB SERVICES
Entity Type:Organization
Organization Name:INDEPENDENT LAB SERVICES
Other - Org Name:INDEPENDENT LAB SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:KENDRA-TOWNSEND
Authorized Official - Suffix:
Authorized Official - Credentials:CCS
Authorized Official - Phone:330-629-2888
Mailing Address - Street 1:1027 BOARDMAN CANFIELD RD
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-4227
Mailing Address - Country:US
Mailing Address - Phone:330-629-2888
Mailing Address - Fax:330-629-2946
Practice Address - Street 1:590 E WESTERN RESERVE RD
Practice Address - Street 2:BUILDING 5
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44514-3354
Practice Address - Country:US
Practice Address - Phone:330-403-8034
Practice Address - Fax:330-629-2966
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADO HEALTH SERVICES INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-22
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36D2068849291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH26184OtherCOLA
OH0115372Medicaid
IN201353260 AMedicaid
OH36D2110782OtherCLIA
OH0115372Medicaid