Provider Demographics
NPI:1659301349
Name:RM LAB LLC
Entity Type:Organization
Organization Name:RM LAB LLC
Other - Org Name:EXPRESS LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VON
Authorized Official - Middle Name:
Authorized Official - Last Name:CROFTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-523-1122
Mailing Address - Street 1:3910 WASHINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7596
Mailing Address - Country:US
Mailing Address - Phone:208-529-8330
Mailing Address - Fax:208-884-4611
Practice Address - Street 1:2220 E 25TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7542
Practice Address - Country:US
Practice Address - Phone:208-529-8330
Practice Address - Fax:208-523-3318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID13D0520868291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806230600Medicaid
ID1400637Medicare ID - Type Unspecified