Provider Demographics
NPI:1760590343
Name:ADVANCED MEDICAL LABORATORY
Entity Type:Organization
Organization Name:ADVANCED MEDICAL LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:NOMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAKED
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:928-344-8525
Mailing Address - Street 1:PO BOX 4548
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85366-4548
Mailing Address - Country:US
Mailing Address - Phone:928-344-8525
Mailing Address - Fax:928-726-3434
Practice Address - Street 1:2435 S AVENUE A
Practice Address - Street 2:SUITE 4
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7175
Practice Address - Country:US
Practice Address - Phone:928-344-8525
Practice Address - Fax:928-726-3434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZL325PVL291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0336330OtherBLUE CROSS OF ARIZONA
AZAZ0336330OtherBLUE CROSS OF ARIZONA