Provider Demographics
NPI:1205612215
Name:LEGACII CLINICAL LABORATORY SERVICES
Entity type:Organization
Organization Name:LEGACII CLINICAL LABORATORY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:L'TIA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:317-918-7542
Mailing Address - Street 1:6613 HAZELHATCH DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-8633
Mailing Address - Country:US
Mailing Address - Phone:317-918-7542
Mailing Address - Fax:
Practice Address - Street 1:8695 CONNECTICUT ST STE C
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6240
Practice Address - Country:US
Practice Address - Phone:219-525-4130
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-05
Last Update Date:2023-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center