Provider Demographics
NPI:1790932820
Name:BRADSHAW MOUNTAIN DIAGNOSTIC LABORATORY INC
Entity Type:Organization
Organization Name:BRADSHAW MOUNTAIN DIAGNOSTIC LABORATORY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:FELLOWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-778-7823
Mailing Address - Street 1:990 WILLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1640
Mailing Address - Country:US
Mailing Address - Phone:928-778-7823
Mailing Address - Fax:928-778-9419
Practice Address - Street 1:7732 EAST FLORENTINE RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314
Practice Address - Country:US
Practice Address - Phone:928-772-5889
Practice Address - Fax:928-775-5678
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRADSHAW MOUNTAIN DIAGNOSTIC LABORATORY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-20
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory