Provider Demographics
NPI:1417317553
Name:CAPITAL DIAGNOSTIC LABORATORY LLC
Entity Type:Organization
Organization Name:CAPITAL DIAGNOSTIC LABORATORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TECHNICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:IBTIHAJ
Authorized Official - Middle Name:
Authorized Official - Last Name:AWADELKARIEM
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:703-321-6502
Mailing Address - Street 1:51 STREET OF DREAMS
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25403-1134
Mailing Address - Country:US
Mailing Address - Phone:703-321-6502
Mailing Address - Fax:
Practice Address - Street 1:46440 BENEDICT DR
Practice Address - Street 2:SUITE 104
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20164-6602
Practice Address - Country:US
Practice Address - Phone:703-321-6502
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-02
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA188023291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory