Provider Demographics
NPI:1952057747
Name:PRIME EXPRESS LABORATORY LLC
Entity Type:Organization
Organization Name:PRIME EXPRESS LABORATORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VINNETTA
Authorized Official - Middle Name:ASHIRAH
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:877-407-6537
Mailing Address - Street 1:7607 W TOWNSEND ST STE 105
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-3965
Mailing Address - Country:US
Mailing Address - Phone:877-407-6537
Mailing Address - Fax:
Practice Address - Street 1:7607 W TOWNSEND ST STE 105
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-3965
Practice Address - Country:US
Practice Address - Phone:877-407-6537
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-01
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service