Provider Demographics
NPI:1336556745
Name:CERTIGEN LABORATORY, LLC
Entity Type:Organization
Organization Name:CERTIGEN LABORATORY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:KIMREY
Authorized Official - Suffix:
Authorized Official - Credentials:MT(ASCP)
Authorized Official - Phone:918-960-3150
Mailing Address - Street 1:PO BOX 722143
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-8624
Mailing Address - Country:US
Mailing Address - Phone:918-960-3150
Mailing Address - Fax:918-960-3154
Practice Address - Street 1:9309 S TOLEDO AVE
Practice Address - Street 2:SUITE A
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-2752
Practice Address - Country:US
Practice Address - Phone:918-960-3150
Practice Address - Fax:918-960-3154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-17
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK37D2075661291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory