Provider Demographics
NPI:1467774695
Name:MIAMI VALLEY CCK LABORATORY
Entity Type:Organization
Organization Name:MIAMI VALLEY CCK LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:YAREMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-478-2011
Mailing Address - Street 1:6818 LOOP RD
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-2159
Mailing Address - Country:US
Mailing Address - Phone:937-478-2011
Mailing Address - Fax:
Practice Address - Street 1:6818 LOOP RD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-2159
Practice Address - Country:US
Practice Address - Phone:937-478-2011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-15
Last Update Date:2010-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory