Provider Demographics
NPI:1780160770
Name:GULF COAST MOLECULAR LABORATORIES, LLC
Entity type:Organization
Organization Name:GULF COAST MOLECULAR LABORATORIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-494-2540
Mailing Address - Street 1:11617 HWY 31
Mailing Address - Street 2:UNIT 3
Mailing Address - City:SPANISH FORT
Mailing Address - State:AL
Mailing Address - Zip Code:36527
Mailing Address - Country:US
Mailing Address - Phone:251-494-2540
Mailing Address - Fax:251-930-6727
Practice Address - Street 1:11617 HWY 31
Practice Address - Street 2:UNIT 3
Practice Address - City:SPANISH FORT
Practice Address - State:AL
Practice Address - Zip Code:36527
Practice Address - Country:US
Practice Address - Phone:251-494-2540
Practice Address - Fax:205-374-8606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-13
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL227036Medicaid
TX427926701Medicaid