Provider Demographics
NPI:1467213249
Name:YOUR MAIN LAB
Entity Type:Organization
Organization Name:YOUR MAIN LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-931-1161
Mailing Address - Street 1:4932 S VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-6016
Mailing Address - Country:US
Mailing Address - Phone:775-409-3917
Mailing Address - Fax:775-409-3116
Practice Address - Street 1:4932 S VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-6016
Practice Address - Country:US
Practice Address - Phone:775-409-3917
Practice Address - Fax:775-409-3116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-19
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory