Provider Demographics
NPI:1801851233
Name:WOODBURY CLINICAL LABORATORY, INC.
Entity Type:Organization
Organization Name:WOODBURY CLINICAL LABORATORY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:DELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:OLDHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-443-7588
Mailing Address - Street 1:PO BOX 2309
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37088-2309
Mailing Address - Country:US
Mailing Address - Phone:615-443-7588
Mailing Address - Fax:615-443-7458
Practice Address - Street 1:305 E HIGH ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-2901
Practice Address - Country:US
Practice Address - Phone:615-443-7588
Practice Address - Fax:615-443-7458
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMERICAN ESOTERIC LABORATORIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-19
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000002135291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0000002135OtherSTATE MEDICAL LABORATORY
TN44D0659026OtherCLIA CERTIFICATE OF COMPL
TNA97909Medicare UPIN
TN44D0659026OtherCLIA CERTIFICATE OF COMPL