Provider Demographics
NPI:1710211149
Name:SPRINGFIELD MASONIC COMMUNITY
Entity Type:Organization
Organization Name:SPRINGFIELD MASONIC COMMUNITY
Other - Org Name:SPRINGFIELD MASONIC COMMUNITY - LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARION
Authorized Official - Middle Name:
Authorized Official - Last Name:LEEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-525-3000
Mailing Address - Street 1:3 MASONIC DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-3658
Mailing Address - Country:US
Mailing Address - Phone:937-525-3000
Mailing Address - Fax:
Practice Address - Street 1:3 MASONIC DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-3658
Practice Address - Country:US
Practice Address - Phone:937-525-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OHIO MASONIC HOME
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-02
Last Update Date:2009-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36D0917924291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory