Provider Demographics
NPI:1437130879
Name:NORTH COAST CLINICAL LABORATORY, INC.
Entity Type:Organization
Organization Name:NORTH COAST CLINICAL LABORATORY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:C
Authorized Official - Last Name:RUNNER
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, MT(ASCP), SM(AA
Authorized Official - Phone:419-626-6012
Mailing Address - Street 1:2215 CLEVELAND RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-4485
Mailing Address - Country:US
Mailing Address - Phone:419-626-6012
Mailing Address - Fax:419-626-0814
Practice Address - Street 1:2215 CLEVELAND RD
Practice Address - Street 2:SUITE 105
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-4485
Practice Address - Country:US
Practice Address - Phone:419-626-6012
Practice Address - Fax:419-626-0814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-11
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0634273Medicaid
MI36D0344271Medicaid
MI36D0344271Medicaid