Provider Demographics
NPI:1922143825
Name:ADVANCED CLINICAL LAB
Entity Type:Organization
Organization Name:ADVANCED CLINICAL LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:
Authorized Official - Last Name:HOPE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:504-338-9858
Mailing Address - Street 1:1405 AIRLINE DR
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70001-5901
Mailing Address - Country:US
Mailing Address - Phone:504-520-8970
Mailing Address - Fax:504-520-8971
Practice Address - Street 1:1405 AIRLINE DR
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-5901
Practice Address - Country:US
Practice Address - Phone:504-520-8970
Practice Address - Fax:504-520-8971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1626325Medicaid
LA1626325Medicaid