Provider Demographics
NPI:1134104789
Name:WAYNEMEDICAL CENTER LLC LAB
Entity Type:Organization
Organization Name:WAYNEMEDICAL CENTER LLC LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:GAYLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-223-4233
Mailing Address - Street 1:RR 4 BOX 4515
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:MO
Mailing Address - Zip Code:63957-9417
Mailing Address - Country:US
Mailing Address - Phone:573-223-4233
Mailing Address - Fax:573-223-2136
Practice Address - Street 1:RR 4 BOX 4515
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:MO
Practice Address - Zip Code:63957-9417
Practice Address - Country:US
Practice Address - Phone:573-223-4233
Practice Address - Fax:573-223-2136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-07
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO701080608Medicaid