Provider Demographics
NPI:1386214369
Name:ODET DIAGNOSTIC LABORATORY LLC
Entity Type:Organization
Organization Name:ODET DIAGNOSTIC LABORATORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:
Authorized Official - Last Name:ODETUYI
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:919-924-2240
Mailing Address - Street 1:5906 FORUM SQ
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703-2890
Mailing Address - Country:US
Mailing Address - Phone:919-924-2240
Mailing Address - Fax:
Practice Address - Street 1:5906 FORUM SQ
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-2890
Practice Address - Country:US
Practice Address - Phone:919-924-2240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory