Provider Demographics
NPI:1790179422
Name:MIDWEST TOXICOLOGY GROUP, LLC
Entity Type:Organization
Organization Name:MIDWEST TOXICOLOGY GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:E
Authorized Official - Last Name:HIMPLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-303-1055
Mailing Address - Street 1:777 CRAIG RD
Mailing Address - Street 2:#230
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7138
Mailing Address - Country:US
Mailing Address - Phone:225-303-1055
Mailing Address - Fax:314-442-4045
Practice Address - Street 1:777 CRAIG RD
Practice Address - Street 2:#230
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-7138
Practice Address - Country:US
Practice Address - Phone:225-303-1055
Practice Address - Fax:314-442-4045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-19
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0000OtherINDEPENDENT CLINICAL LABORATORY