Provider Demographics
NPI:1659596161
Name:PROLAB SERVICSE INC
Entity Type:Organization
Organization Name:PROLAB SERVICSE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHANNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:LOOTENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-659-5460
Mailing Address - Street 1:1705 CHRISTY DR STE 105
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-5195
Mailing Address - Country:US
Mailing Address - Phone:573-659-5460
Mailing Address - Fax:
Practice Address - Street 1:1705 CHRISTY DR STE 105
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-5195
Practice Address - Country:US
Practice Address - Phone:573-659-5460
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory