Provider Demographics
NPI:1831427962
Name:SIGNATURE MEDICAL LABORATORY
Entity type:Organization
Organization Name:SIGNATURE MEDICAL LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:D
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-758-4601
Mailing Address - Street 1:201 SIGNATURE PL
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-3376
Mailing Address - Country:US
Mailing Address - Phone:615-444-7999
Mailing Address - Fax:615-444-7765
Practice Address - Street 1:1097 WESTON DR
Practice Address - Street 2:SUITE 1
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-3493
Practice Address - Country:US
Practice Address - Phone:615-758-4601
Practice Address - Fax:615-754-7074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-01
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory