Provider Demographics
NPI:1437533254
Name:OTTENDORF LABORATORIES, LLC
Entity Type:Organization
Organization Name:OTTENDORF LABORATORIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER AND MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KONRAD
Authorized Official - Middle Name:H
Authorized Official - Last Name:KAEDING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-593-5904
Mailing Address - Street 1:3922 GISBOURNE DR
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:27282-7706
Mailing Address - Country:US
Mailing Address - Phone:302-518-3022
Mailing Address - Fax:
Practice Address - Street 1:1095 INVESTMENT BLVD
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-1799
Practice Address - Country:US
Practice Address - Phone:919-390-3566
Practice Address - Fax:919-629-8402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-10
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1437533254Medicaid