Provider Demographics
NPI:1598266421
Name:CORE DIAGNOSTIC LABORATORIES LLC
Entity Type:Organization
Organization Name:CORE DIAGNOSTIC LABORATORIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-508-5939
Mailing Address - Street 1:211 SUMMIT PKWY STE 124
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-4742
Mailing Address - Country:US
Mailing Address - Phone:205-508-5939
Mailing Address - Fax:
Practice Address - Street 1:211 SUMMIT PKWY STE 124
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35209-4742
Practice Address - Country:US
Practice Address - Phone:205-534-5114
Practice Address - Fax:205-278-6939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-26
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL01D2144684291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL220224Medicaid