Provider Demographics
NPI:1568068609
Name:CERTIFIED LABORATORY SERVICES
Entity Type:Organization
Organization Name:CERTIFIED LABORATORY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-685-7530
Mailing Address - Street 1:2041 E 3RD DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-1401
Mailing Address - Country:US
Mailing Address - Phone:480-685-7530
Mailing Address - Fax:480-900-8853
Practice Address - Street 1:2041 E 3RD DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-1401
Practice Address - Country:US
Practice Address - Phone:480-685-7530
Practice Address - Fax:480-900-8853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ03D2197602OtherUS DEPT OF HEALTH AND HUMAN SERVICES