Provider Demographics
NPI:1609963834
Name:VALLEY DIAGNOSTIC LABORATORIES INC
Entity Type:Organization
Organization Name:VALLEY DIAGNOSTIC LABORATORIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:G
Authorized Official - Last Name:GOLDCAMP
Authorized Official - Suffix:
Authorized Official - Credentials:MT(ASCP)
Authorized Official - Phone:740-446-0353
Mailing Address - Street 1:1504 JACKSON PIKE
Mailing Address - Street 2:P.O.BOX 33
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1387
Mailing Address - Country:US
Mailing Address - Phone:740-446-0353
Mailing Address - Fax:740-441-0733
Practice Address - Street 1:1504 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1387
Practice Address - Country:US
Practice Address - Phone:740-446-0353
Practice Address - Fax:740-441-0733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH570251291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0040425000Medicaid
OH0489038Medicaid
KY37902236Medicaid
OH1278070Medicare ID - Type UnspecifiedUNITED MINE WORKERS
OH0489038Medicaid
OH690000381Medicare ID - Type UnspecifiedRAILROAD MEDICARE