Provider Demographics
NPI:1295848208
Name:PHYSICIANS REFERENCE LABORATORY, INC.
Entity Type:Organization
Organization Name:PHYSICIANS REFERENCE LABORATORY, INC.
Other - Org Name:PHYSICIANS REFERENCE LABORATORY, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LAB MANGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:GORHAM
Authorized Official - Last Name:ROLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:423-886-1212
Mailing Address - Street 1:243 SIGNAL MOUNTAIN RD
Mailing Address - Street 2:SUITE G
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37405-1933
Mailing Address - Country:US
Mailing Address - Phone:423-266-1222
Mailing Address - Fax:423-266-1271
Practice Address - Street 1:243 SIGNAL MOUNTAIN RD
Practice Address - Street 2:SUITE G
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37405-1933
Practice Address - Country:US
Practice Address - Phone:423-266-1222
Practice Address - Fax:423-266-1271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000004059291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4059OtherTENNESSE STATE LICIENSE
TN3404207Medicare ID - Type Unspecified