Provider Demographics
NPI:1669822276
Name:RED ROCK LABRATORY
Entity Type:Organization
Organization Name:RED ROCK LABRATORY
Other - Org Name:RED ROCK LABORATORY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER REGISTERED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:TAZ
Authorized Official - Middle Name:HARDY
Authorized Official - Last Name:DECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-897-5900
Mailing Address - Street 1:120 W 1470 S
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-6798
Mailing Address - Country:US
Mailing Address - Phone:801-897-5900
Mailing Address - Fax:
Practice Address - Street 1:120 W 1470 S
Practice Address - Street 2:SUITE 200
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-6798
Practice Address - Country:US
Practice Address - Phone:801-897-5900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT46D2112751291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT46D2112751OtherCLINICAL LABORATORY IMPROVEMENT AMENDMENTS (CLIA) HIGH COMPLEXITY