Provider Demographics
NPI:1750990552
Name:CENTENNIAL STATE LAB, LLC
Entity type:Organization
Organization Name:CENTENNIAL STATE LAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-284-3522
Mailing Address - Street 1:651 CORPORATE CIR STE 104
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80401-5652
Mailing Address - Country:US
Mailing Address - Phone:303-800-2595
Mailing Address - Fax:303-800-2596
Practice Address - Street 1:651 CORPORATE CIR STE 104
Practice Address - Street 2:
Practice Address - City:GOLDEN
Practice Address - State:CO
Practice Address - Zip Code:80401-5652
Practice Address - Country:US
Practice Address - Phone:303-800-2595
Practice Address - Fax:303-800-2596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory