Provider Demographics
NPI:1861862799
Name:CENTRAL DIAGNOSTIC LAB LLC
Entity Type:Organization
Organization Name:CENTRAL DIAGNOSTIC LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASIM
Authorized Official - Middle Name:
Authorized Official - Last Name:ALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-731-6355
Mailing Address - Street 1:PO BOX 776341
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6341
Mailing Address - Country:US
Mailing Address - Phone:314-731-6355
Mailing Address - Fax:314-731-6399
Practice Address - Street 1:456 N NEW BALLAS RD STE 196
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6812
Practice Address - Country:US
Practice Address - Phone:314-731-6355
Practice Address - Fax:314-731-6399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-05
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory