Provider Demographics
NPI:1548386642
Name:DPG REFERENCE LAB, PLLC
Entity Type:Organization
Organization Name:DPG REFERENCE LAB, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGED CARE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-725-7551
Mailing Address - Street 1:1211 UNION AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-6638
Mailing Address - Country:US
Mailing Address - Phone:901-725-7551
Mailing Address - Fax:901-726-6085
Practice Address - Street 1:220 S CLAYBROOK ST
Practice Address - Street 2:SUITE 401
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-3527
Practice Address - Country:US
Practice Address - Phone:901-725-7551
Practice Address - Fax:901-726-6085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0453898291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory