Provider Demographics
NPI:1851400071
Name:MCCOWAN CLINICAL LABORATORY, INC
Entity Type:Organization
Organization Name:MCCOWAN CLINICAL LABORATORY, INC
Other - Org Name:DH MCCOWAN MEDICAL LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LAB MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GAYL
Authorized Official - Middle Name:
Authorized Official - Last Name:TROYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-267-7853
Mailing Address - Street 1:178 W COMMERCIAL AVE
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-1636
Mailing Address - Country:US
Mailing Address - Phone:541-267-7853
Mailing Address - Fax:541-267-4025
Practice Address - Street 1:178 W COMMERCIAL AVE
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-1636
Practice Address - Country:US
Practice Address - Phone:541-267-7853
Practice Address - Fax:541-267-4025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR116103Medicaid
ORR173487Medicare PIN