Provider Demographics
NPI:1750722245
Name:AUDUBON FERTILITY LABORATORY
Entity type:Organization
Organization Name:AUDUBON FERTILITY LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LAB DIRECTOR AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:RONALD
Authorized Official - Last Name:CLISHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-891-1390
Mailing Address - Street 1:4321 MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70115-6227
Mailing Address - Country:US
Mailing Address - Phone:504-891-1390
Mailing Address - Fax:504-891-1391
Practice Address - Street 1:4321 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70115-6227
Practice Address - Country:US
Practice Address - Phone:504-891-1390
Practice Address - Fax:504-891-1391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-11
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA19D2010657291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory