Provider Demographics
NPI:1801390521
Name:LOCAL LAB LLC
Entity Type:Organization
Organization Name:LOCAL LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MORGANA
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMORA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-929-2234
Mailing Address - Street 1:8382 N WAYNE DR STE 201
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-6028
Mailing Address - Country:US
Mailing Address - Phone:208-714-0478
Mailing Address - Fax:855-485-5234
Practice Address - Street 1:8382 N WAYNE DR STE 201
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-6028
Practice Address - Country:US
Practice Address - Phone:208-714-0478
Practice Address - Fax:855-485-5234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-19
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID13291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID13D2141188OtherCLIA ID