Provider Demographics
NPI:1417928433
Name:LAWRENCE CLINICAL LABORATORY CHARTERED
Entity Type:Organization
Organization Name:LAWRENCE CLINICAL LABORATORY CHARTERED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:MODDRELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:785-749-6100
Mailing Address - Street 1:PO BOX 442157
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044-8933
Mailing Address - Country:US
Mailing Address - Phone:316-685-8428
Mailing Address - Fax:
Practice Address - Street 1:325 MAINE ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-1360
Practice Address - Country:US
Practice Address - Phone:785-749-6100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Not Answered207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS003981OtherBCBS
CS1532OtherRAILROAD MEDICARE
KS003981OtherBCBS
KS003981OtherBCBS