Provider Demographics
NPI:1376081612
Name:MOUNTAINEER LABORATORIES LLC
Entity Type:Organization
Organization Name:MOUNTAINEER LABORATORIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-888-6976
Mailing Address - Street 1:6029 BELT LINE RD STE 210
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-7964
Mailing Address - Country:US
Mailing Address - Phone:214-888-6976
Mailing Address - Fax:888-845-7740
Practice Address - Street 1:1337 VIRGINIA ST E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-3011
Practice Address - Country:US
Practice Address - Phone:214-888-6976
Practice Address - Fax:888-845-7740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-07
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory