Provider Demographics
NPI:1295736841
Name:ARCHER CLINIC LABORATORY
Entity type:Organization
Organization Name:ARCHER CLINIC LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NOEL
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GILLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-886-6302
Mailing Address - Street 1:400 UNIVERSITY DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-1080
Mailing Address - Country:US
Mailing Address - Phone:606-886-6302
Mailing Address - Fax:606-886-0597
Practice Address - Street 1:400 UNIVERSITY DR
Practice Address - Street 2:SUITE 105
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-1080
Practice Address - Country:US
Practice Address - Phone:606-886-6302
Practice Address - Fax:606-886-0597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-04
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY200111291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY37901055Medicaid
KY4002701Medicare ID - Type Unspecified