Provider Demographics
NPI:1164710893
Name:LABTRAN CLINICAL LABORATORIES, LLC
Entity Type:Organization
Organization Name:LABTRAN CLINICAL LABORATORIES, LLC
Other - Org Name:LABTRAN CLINICAL LABORATORIES, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:LAFURGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-852-0302
Mailing Address - Street 1:106 WESTHILL DRIVE, UNIT D.
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087
Mailing Address - Country:US
Mailing Address - Phone:855-522-8726
Mailing Address - Fax:888-581-0336
Practice Address - Street 1:2404 E MILL PLAIN BLVD STE B
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-4334
Practice Address - Country:US
Practice Address - Phone:855-522-8726
Practice Address - Fax:888-581-0336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-15
Last Update Date:2013-07-25
Deactivation Date:2013-04-03
Deactivation Code:
Reactivation Date:2013-04-10
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN44D2028000Medicaid