Provider Demographics
NPI:1972970341
Name:PROVIDER LABORATORY SERVICES LLC
Entity Type:Organization
Organization Name:PROVIDER LABORATORY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:VURGASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-333-3278
Mailing Address - Street 1:PO BOX 1150
Mailing Address - Street 2:306 RODMAN ROAD
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04211-1150
Mailing Address - Country:US
Mailing Address - Phone:207-333-3278
Mailing Address - Fax:207-333-3037
Practice Address - Street 1:88 OXFORD ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7825
Practice Address - Country:US
Practice Address - Phone:207-241-7722
Practice Address - Fax:207-312-5677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-01
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory