Provider Demographics
NPI:1619073947
Name:LONGMONT CLINIC LAB
Entity Type:Organization
Organization Name:LONGMONT CLINIC LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-776-1234
Mailing Address - Street 1:1925 MOUNTAIN VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3128
Mailing Address - Country:US
Mailing Address - Phone:303-776-1234
Mailing Address - Fax:720-494-3107
Practice Address - Street 1:1925 MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3128
Practice Address - Country:US
Practice Address - Phone:303-776-1234
Practice Address - Fax:720-494-3107
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LONGMONT CLINIC PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10251530000291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO67663Medicare ID - Type Unspecified