Provider Demographics
NPI:1518084953
Name:WESTERN BIOLOGICAL LABORATORY, INC.
Entity Type:Organization
Organization Name:WESTERN BIOLOGICAL LABORATORY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:BURT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:801-278-9206
Mailing Address - Street 1:2180 E 4500 S
Mailing Address - Street 2:SUITE 292
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4434
Mailing Address - Country:US
Mailing Address - Phone:801-278-9206
Mailing Address - Fax:801-278-9287
Practice Address - Street 1:2180 E 4500 S
Practice Address - Street 2:SUITE 292
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-4434
Practice Address - Country:US
Practice Address - Phone:801-278-9206
Practice Address - Fax:801-278-9287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT46D0865144291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT46D0865144OtherCLIA NUMBER
UT=========004Medicaid
UT46D0865144OtherCLIA NUMBER