Provider Demographics
NPI:1578568119
Name:COMPUNET CLINICAL LABORATORIES LLC
Entity Type:Organization
Organization Name:COMPUNET CLINICAL LABORATORIES LLC
Other - Org Name:COMPUNET CLINICAL LABORATORIES LTD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CFO/VP FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MANIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-297-8202
Mailing Address - Street 1:2308 SANDRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1847
Mailing Address - Country:US
Mailing Address - Phone:937-296-0844
Mailing Address - Fax:937-297-8232
Practice Address - Street 1:1 WYOMING ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2722
Practice Address - Country:US
Practice Address - Phone:937-296-0844
Practice Address - Fax:937-297-8232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0895509Medicaid
OHD368011Medicare PIN