Provider Demographics
NPI:1174850408
Name:DIAGNOSTIC LABORATORY OF OKLAHOMA, LLC
Entity Type:Organization
Organization Name:DIAGNOSTIC LABORATORY OF OKLAHOMA, LLC
Other - Org Name:INTEGRIS CANCER INSTITUTE
Other - Org Type:Other Name
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:LEO
Authorized Official - Middle Name:
Authorized Official - Last Name:SELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-608-6298
Mailing Address - Street 1:1201 S COLLEGEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:COLLEGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19426-2998
Mailing Address - Country:US
Mailing Address - Phone:866-697-8378
Mailing Address - Fax:
Practice Address - Street 1:5911 WEST MEMORIAL ROAD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73142
Practice Address - Country:US
Practice Address - Phone:405-609-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIAGNOSTIC LABORATORY OF OKLAHOMA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-11-06
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100758750Medicaid
400522083Medicare PIN