Provider Demographics
NPI:1154326668
Name:TWIN RIVERS MEDICAL LABORATORY, INC
Entity Type:Organization
Organization Name:TWIN RIVERS MEDICAL LABORATORY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:LOUELLEN
Authorized Official - Last Name:BOSTIC
Authorized Official - Suffix:
Authorized Official - Credentials:RMT
Authorized Official - Phone:574-739-0004
Mailing Address - Street 1:902 W. BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-2978
Mailing Address - Country:US
Mailing Address - Phone:574-739-0004
Mailing Address - Fax:574-739-0105
Practice Address - Street 1:902 W. BROADWAY
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-2978
Practice Address - Country:US
Practice Address - Phone:574-739-0004
Practice Address - Fax:574-739-0105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN982870Medicare PIN