Provider Demographics
NPI:1457805533
Name:COMMUNITY MEDICAL LABORATORY, LLC
Entity Type:Organization
Organization Name:COMMUNITY MEDICAL LABORATORY, LLC
Other - Org Name:COMMUNITY MEDICAL LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-733-6170
Mailing Address - Street 1:1695 MESQUITE AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5687
Mailing Address - Country:US
Mailing Address - Phone:928-733-6170
Mailing Address - Fax:
Practice Address - Street 1:1695 MESQUITE AVE STE 202
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5687
Practice Address - Country:US
Practice Address - Phone:928-733-6170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-06
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
03D2115501291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory