Provider Demographics
NPI:1467612895
Name:MEQUON LABS INC
Entity Type:Organization
Organization Name:MEQUON LABS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:KANE
Authorized Official - Suffix:III
Authorized Official - Credentials:LCSW
Authorized Official - Phone:262-240-0427
Mailing Address - Street 1:10500 N PORT WASHINGTON ROAD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092
Mailing Address - Country:US
Mailing Address - Phone:262-240-0427
Mailing Address - Fax:262-240-0429
Practice Address - Street 1:10500 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5585
Practice Address - Country:US
Practice Address - Phone:262-240-0427
Practice Address - Fax:262-240-0429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36204000Medicaid