Provider Demographics
NPI:1639465677
Name:SOUTHERN CLINICAL LABORATORY
Entity Type:Organization
Organization Name:SOUTHERN CLINICAL LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:JONES
Authorized Official - Last Name:PROVOST
Authorized Official - Suffix:
Authorized Official - Credentials:MBA/HCM MASTER HEALT
Authorized Official - Phone:504-508-0734
Mailing Address - Street 1:86 NORTON AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:ARABI
Mailing Address - State:LA
Mailing Address - Zip Code:70032
Mailing Address - Country:US
Mailing Address - Phone:504-682-5334
Mailing Address - Fax:504-682-5336
Practice Address - Street 1:86 NORTON AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:ARABI
Practice Address - State:LA
Practice Address - Zip Code:70032
Practice Address - Country:US
Practice Address - Phone:504-682-5334
Practice Address - Fax:504-682-5336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-28
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA404542930291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory