Provider Demographics
NPI:1477591121
Name:CLINICAL LABORATORY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:CLINICAL LABORATORY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:WARGOTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-552-8118
Mailing Address - Street 1:PO BOX 1147
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20725-1147
Mailing Address - Country:US
Mailing Address - Phone:301-498-2922
Mailing Address - Fax:301-498-3074
Practice Address - Street 1:8118 GOOD LUCK RD
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-3595
Practice Address - Country:US
Practice Address - Phone:301-552-8118
Practice Address - Fax:301-498-3074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC3437OtherBCBS GROUP PROVIDER #
MD260100100Medicaid
MDW450CLOtherBCBS GROUP PROVIDER #
DC000305Medicare PIN