Provider Demographics
NPI:1255514329
Name:DIAGNOSTIC LABORATORY OF OKLAHOMA LLC
Entity type:Organization
Organization Name:DIAGNOSTIC LABORATORY OF OKLAHOMA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:LEO
Authorized Official - Middle Name:
Authorized Official - Last Name:SELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-608-6298
Mailing Address - Street 1:2750 MONROE BLVD
Mailing Address - Street 2:
Mailing Address - City:EAGLEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19403-2429
Mailing Address - Country:US
Mailing Address - Phone:484-676-7000
Mailing Address - Fax:
Practice Address - Street 1:200 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-6830
Practice Address - Country:US
Practice Address - Phone:918-542-6611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK37D0667302291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100758750PMedicaid