Provider Demographics
NPI:1861495921
Name:HEMATOLOGY ONCOLOGY LIFE CENTER PRESCOTT
Entity Type:Organization
Organization Name:HEMATOLOGY ONCOLOGY LIFE CENTER PRESCOTT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:WOLD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-442-2232
Mailing Address - Street 1:PO BOX 8255
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71306-1255
Mailing Address - Country:US
Mailing Address - Phone:318-442-2232
Mailing Address - Fax:318-442-2192
Practice Address - Street 1:2003 MACARTHUR DR
Practice Address - Street 2:STE 5
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3720
Practice Address - Country:US
Practice Address - Phone:318-619-7707
Practice Address - Fax:318-619-7771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA19D1020000291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA19D1020000OtherCLIA ID #