Provider Demographics
NPI:1417948969
Name:M&T DIAGNOSTIC LAB SERVICES
Entity Type:Organization
Organization Name:M&T DIAGNOSTIC LAB SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:K
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:ASCP
Authorized Official - Phone:620-515-0619
Mailing Address - Street 1:1411 W 4TH ST
Mailing Address - Street 2:PO BOX 312
Mailing Address - City:COFFEYVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:67337-3300
Mailing Address - Country:US
Mailing Address - Phone:620-251-3666
Mailing Address - Fax:
Practice Address - Street 1:1411 W 4TH ST
Practice Address - Street 2:
Practice Address - City:COFFEYVILLE
Practice Address - State:KS
Practice Address - Zip Code:67337-3300
Practice Address - Country:US
Practice Address - Phone:620-251-3666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-03
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSP00268596OtherRAILROAD MEDICARE
KS117934Medicare PIN