Provider Demographics
NPI:1750707899
Name:MID AMERICA CLINICAL LABORATORIES, LLC
Entity type:Organization
Organization Name:MID AMERICA CLINICAL LABORATORIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O./GENERAL MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANNE
Authorized Official - Middle Name:Z
Authorized Official - Last Name:VANNESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-803-1010
Mailing Address - Street 1:2560 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-1705
Mailing Address - Country:US
Mailing Address - Phone:317-803-1010
Mailing Address - Fax:317-803-0186
Practice Address - Street 1:8111 TOWNSHIP LINE RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2479
Practice Address - Country:US
Practice Address - Phone:317-415-7657
Practice Address - Fax:617-415-7658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-13
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN15D1035790291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN15D1035790OtherCLIA