Provider Demographics
NPI:1326364258
Name:CARONDELET LABORATORY SERVICES INC
Entity Type:Organization
Organization Name:CARONDELET LABORATORY SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:BANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-472-0380
Mailing Address - Street 1:1660 LAKESIDE DR
Mailing Address - Street 2:STE 466
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-6544
Mailing Address - Country:US
Mailing Address - Phone:888-472-0380
Mailing Address - Fax:
Practice Address - Street 1:1601 W SAINT MARYS RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-2623
Practice Address - Country:US
Practice Address - Phone:888-472-0380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-16
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ03D0914817291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory