Provider Demographics
NPI:1548794175
Name:RESTORATION LAB SERVICES LLC
Entity Type:Organization
Organization Name:RESTORATION LAB SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKERNAN
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:612-767-9525
Mailing Address - Street 1:3805 WASHINGTON AVENUE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55412-1714
Mailing Address - Country:US
Mailing Address - Phone:612-767-9525
Mailing Address - Fax:
Practice Address - Street 1:3805 WASHINGTON AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55412-2141
Practice Address - Country:US
Practice Address - Phone:612-677-2668
Practice Address - Fax:612-767-6603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-20
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory