Provider Demographics
NPI:1639136187
Name:MISSISSIPPI VALLEY LABORATORY, LLC
Entity Type:Organization
Organization Name:MISSISSIPPI VALLEY LABORATORY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:FARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MT ASCP
Authorized Official - Phone:563-344-6692
Mailing Address - Street 1:3400 DEXTER CT
Mailing Address - Street 2:SUITE 205
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3461
Mailing Address - Country:US
Mailing Address - Phone:563-344-6690
Mailing Address - Fax:563-344-6699
Practice Address - Street 1:3400 DEXTER CT
Practice Address - Street 2:SUITE 205
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3461
Practice Address - Country:US
Practice Address - Phone:563-344-6690
Practice Address - Fax:563-344-6699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0142265Medicaid
IA54573OtherBLUE CROSS BLUE SHIELD
IA0142265Medicaid
IA=========01OtherJOHN DEERE HEALTH