Provider Demographics
NPI:1912000308
Name:UNILAB INC
Entity Type:Organization
Organization Name:UNILAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RITESH
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-341-1255
Mailing Address - Street 1:418 N AUSTIN BLVD
Mailing Address - Street 2:#2A
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2752
Mailing Address - Country:US
Mailing Address - Phone:708-848-1556
Mailing Address - Fax:708-848-1737
Practice Address - Street 1:418 N AUSTIN BLVD
Practice Address - Street 2:#2A
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2752
Practice Address - Country:US
Practice Address - Phone:708-848-1556
Practice Address - Fax:708-848-1737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CLIA14D0646585291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100394470AMedicaid
IN100394470AMedicaid
IL=========001Medicaid