Provider Demographics
NPI:1891204160
Name:ACADIAN DIAGNOSTIC LABORATORIES LLC
Entity Type:Organization
Organization Name:ACADIAN DIAGNOSTIC LABORATORIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:S
Authorized Official - Last Name:WILKS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:225-448-5886
Mailing Address - Street 1:11842 JUSTICE AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-5324
Mailing Address - Country:US
Mailing Address - Phone:225-448-5886
Mailing Address - Fax:225-292-5956
Practice Address - Street 1:2500 S DECKER LAKE BLVD STE 4
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-5782
Practice Address - Country:US
Practice Address - Phone:225-448-5886
Practice Address - Fax:225-292-5956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-29
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT46D2114570OtherCLIA