Provider Demographics
NPI:1598760035
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 1:3737 SOUTHERN BOULEVARD
Practice Address - Street 2:SUITE 3200
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1225
Practice Address - Country:US
Practice Address - Phone:937-297-8253
Practice Address - Fax:937-297-8229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36D0698030291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH690002971OtherRAILROAD MEDICARE
OH2427369Medicaid
OH2427369Medicaid