Provider Demographics
NPI:1124585336
Name:HEALTH FACILITY LABORATORY
Entity Type:Organization
Organization Name:HEALTH FACILITY LABORATORY
Other - Org Name:ULTRA LAB TEST
Other - Org Type:Other Name
Authorized Official - Title/Position:SPECIALIST TECHNOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:CORNELIUS
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-329-1321
Mailing Address - Street 1:229 PAOAKALANI AVE # 714
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96815-3764
Mailing Address - Country:US
Mailing Address - Phone:601-299-8067
Mailing Address - Fax:
Practice Address - Street 1:229 PAOAKALANI AVE # 714
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96815-3764
Practice Address - Country:US
Practice Address - Phone:907-786-4401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-23
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes293D00000XLaboratoriesPhysiological LaboratoryGroup - Single Specialty
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysisGroup - Single Specialty
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGroup - Single Specialty
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS314125401722Medicaid