Provider Demographics
NPI:1831222595
Name:ACCURA MEDICAL LABORATORY INC
Entity type:Organization
Organization Name:ACCURA MEDICAL LABORATORY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PRAKOB
Authorized Official - Middle Name:KARL
Authorized Official - Last Name:PONGSPIKUL
Authorized Official - Suffix:
Authorized Official - Credentials:MT(ASCP), SC, MBA
Authorized Official - Phone:636-978-2228
Mailing Address - Street 1:206 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-2805
Mailing Address - Country:US
Mailing Address - Phone:636-978-2228
Mailing Address - Fax:636-240-0144
Practice Address - Street 1:206 S MAIN ST
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-2805
Practice Address - Country:US
Practice Address - Phone:636-978-2228
Practice Address - Fax:636-240-0144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO26D0691515291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO702946807Medicaid
MO=========001Medicare ID - Type Unspecified
MO000011499Medicare ID - Type Unspecified