Provider Demographics
NPI:1508247073
Name:PRIME LABORATORIES LLC
Entity Type:Organization
Organization Name:PRIME LABORATORIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CONLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-940-3180
Mailing Address - Street 1:1130 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-2388
Mailing Address - Country:US
Mailing Address - Phone:918-940-3180
Mailing Address - Fax:
Practice Address - Street 1:1130 N 9TH ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-2388
Practice Address - Country:US
Practice Address - Phone:918-940-3180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-10
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200622820Medicaid
OK200622820Medicaid