Provider Demographics
NPI:1184022360
Name:MORELAND MEDICAL LABORATORY, LLC
Entity Type:Organization
Organization Name:MORELAND MEDICAL LABORATORY, LLC
Other - Org Name:MORELAND MEDICAL LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:HOPKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-514-4992
Mailing Address - Street 1:1111 DELAFIELD ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3417
Mailing Address - Country:US
Mailing Address - Phone:888-317-0769
Mailing Address - Fax:888-317-0769
Practice Address - Street 1:1111 DELAFIELD ST
Practice Address - Street 2:SUITE 301
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3417
Practice Address - Country:US
Practice Address - Phone:888-317-0769
Practice Address - Fax:888-317-0769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-20
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK300237159Medicare PIN