Provider Demographics
NPI:1780737270
Name:CWCL - COASTAL WOMENS CLINICAL LAB
Entity type:Organization
Organization Name:CWCL - COASTAL WOMENS CLINICAL LAB
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:GAGNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-885-8445
Mailing Address - Street 1:71 US ROUTE ONE
Mailing Address - Street 2:SUITE A, ELEVATION CENTER
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9375
Mailing Address - Country:US
Mailing Address - Phone:207-885-8400
Mailing Address - Fax:207-885-8499
Practice Address - Street 1:71 US ROUTE ONE
Practice Address - Street 2:SUITE A, ELEVATION CENTER
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-9375
Practice Address - Country:US
Practice Address - Phone:207-885-8400
Practice Address - Fax:207-885-8499
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COASTAL WOMENS HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-19
Last Update Date:2010-09-23
Deactivation Date:2008-06-25
Deactivation Code:
Reactivation Date:2008-12-17
Provider Licenses
StateLicense IDTaxonomies
ME20D0088760291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME015617OtherANTHEM STAR NUMBER
ME800794OtherHARVARD PAYEE NUMBER