Provider Demographics
NPI:1659364784
Name:SPECIALTY LABORATORIES, INC.
Entity Type:Organization
Organization Name:SPECIALTY LABORATORIES, INC.
Other - Org Name:MISSION PHARMACAL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:VP, MANAGED CARE
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-932-8270
Mailing Address - Street 1:7111 FAIRWAY DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-4204
Mailing Address - Country:US
Mailing Address - Phone:561-712-6265
Mailing Address - Fax:561-712-7349
Practice Address - Street 1:1325 E DURANGO BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78210-1724
Practice Address - Country:US
Practice Address - Phone:210-581-0574
Practice Address - Fax:210-581-1456
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMERIPATH INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-24
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0028276B332B00000X
TX291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7001173Medicaid
TXLOCL81784Medicaid
CO98800089Medicaid
PA01648843Medicaid
MA0805777Medicaid
MT0000420325Medicaid
KS10031209AMedicaid
AZ424507Medicaid
IL741041775001Medicaid
SCL00085Medicaid
OH2046360Medicaid
IA0511352Medicaid
LA1540056Medicaid
GA00738845AMedicaid
CAXLAB01421Medicaid
MA0805777Medicaid
GA00738845AMedicaid