Provider Demographics
NPI:1609565027
Name:FOUNDATIONS DIAGNOSTIC LABORATORY LLC
Entity Type:Organization
Organization Name:FOUNDATIONS DIAGNOSTIC LABORATORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:L
Authorized Official - Last Name:ALSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-264-7793
Mailing Address - Street 1:1139 N CHARLOTTE AVE STE C
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-2512
Mailing Address - Country:US
Mailing Address - Phone:980-210-3151
Mailing Address - Fax:919-276-8381
Practice Address - Street 1:1139 N CHARLOTTE AVE STE C
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-2512
Practice Address - Country:US
Practice Address - Phone:980-210-3151
Practice Address - Fax:919-276-8381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-02
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory