Provider Demographics
NPI:1437695731
Name:MEDICAL LABORATORY SPECIALTY, INC
Entity Type:Organization
Organization Name:MEDICAL LABORATORY SPECIALTY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FERDOUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-703-4227
Mailing Address - Street 1:529 W COLGATE DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-1753
Mailing Address - Country:US
Mailing Address - Phone:480-703-4227
Mailing Address - Fax:
Practice Address - Street 1:3636 ST
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409
Practice Address - Country:US
Practice Address - Phone:928-757-3636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
03D2120368291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory