Provider Demographics
NPI:1760743090
Name:NOVUS LABORATORIES, LLC
Entity Type:Organization
Organization Name:NOVUS LABORATORIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF LABORATORY OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:TERA
Authorized Official - Middle Name:W
Authorized Official - Last Name:COULTER
Authorized Official - Suffix:
Authorized Official - Credentials:AS
Authorized Official - Phone:276-525-4606
Mailing Address - Street 1:14270 LEE HWY
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24202-4316
Mailing Address - Country:US
Mailing Address - Phone:276-525-4606
Mailing Address - Fax:276-525-4608
Practice Address - Street 1:14270 LEE HWY
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24202-4316
Practice Address - Country:US
Practice Address - Phone:276-525-4606
Practice Address - Fax:276-525-4608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-04
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA49D2042544291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1530278Medicaid
VA49D2042544OtherCLIA
VA1760743090Medicaid
TN4334814OtherBC/BS
VA49D2042544Medicare Oscar/Certification
TN4334814OtherBC/BS
Q407300001Medicare UPIN