Provider Demographics
NPI:1871685628
Name:COLLABORATIVE LABORATORY SERVICES LLC
Entity Type:Organization
Organization Name:COLLABORATIVE LABORATORY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:TERRANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:DILLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-596-7220
Mailing Address - Street 1:1005 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-6408
Mailing Address - Country:US
Mailing Address - Phone:641-684-4621
Mailing Address - Fax:641-682-8976
Practice Address - Street 1:1005 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-6413
Practice Address - Country:US
Practice Address - Phone:641-684-4621
Practice Address - Fax:641-682-8976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA16D0387097291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0186841Medicaid
IA1023119120OtherRENDERING PROVIDER
IA04027Medicare PIN