Provider Demographics
NPI:1598192031
Name:MID AMERICA CLINICAL LABORATORIES, LLC
Entity Type:Organization
Organization Name:MID AMERICA CLINICAL LABORATORIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/GENERAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANNE
Authorized Official - Middle Name:Z
Authorized Official - Last Name:VANNESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-803-1010
Mailing Address - Street 1:473 E GREENVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:IN
Mailing Address - Zip Code:47394-9436
Mailing Address - Country:US
Mailing Address - Phone:765-584-0328
Mailing Address - Fax:765-584-0333
Practice Address - Street 1:2560 N SHADELAND AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-1705
Practice Address - Country:US
Practice Address - Phone:317-803-1010
Practice Address - Fax:317-803-0186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN15D0360519291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN15D0360519OtherCLIA