Provider Demographics
NPI:1558348151
Name:LAKE HAVASU MEDICAL LABORATORY,LTD.
Entity Type:Organization
Organization Name:LAKE HAVASU MEDICAL LABORATORY,LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:GWENNA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MARQUIS
Authorized Official - Suffix:
Authorized Official - Credentials:CLS(NCA)
Authorized Official - Phone:928-855-4077
Mailing Address - Street 1:1951 MESQUITE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5746
Mailing Address - Country:US
Mailing Address - Phone:928-855-4077
Mailing Address - Fax:928-855-5470
Practice Address - Street 1:1951 MESQUITE AVE
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5746
Practice Address - Country:US
Practice Address - Phone:928-855-4077
Practice Address - Fax:928-855-5470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ3L0008111Medicare ID - Type UnspecifiedPROVIDER #