Provider Demographics
NPI:1649255688
Name:DIAGNOSTIC LABORATORY PRACTICES
Entity type:Organization
Organization Name:DIAGNOSTIC LABORATORY PRACTICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:LOURI
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-546-0200
Mailing Address - Street 1:PO BOX 72090
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44192-0002
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:
Practice Address - Street 1:2322 E 22ND ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-3176
Practice Address - Country:US
Practice Address - Phone:216-861-6200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2156536Medicaid
OH9308371Medicare PIN