Provider Demographics
NPI:1841657681
Name:PHYSICIAN'S LABORATORY OF MIDWEST CITY, LLC
Entity type:Organization
Organization Name:PHYSICIAN'S LABORATORY OF MIDWEST CITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CARLO
Authorized Official - Middle Name:
Authorized Official - Last Name:LEDESMA
Authorized Official - Suffix:
Authorized Official - Credentials:MT,ASAP,MS
Authorized Official - Phone:405-737-4900
Mailing Address - Street 1:9230 E. RENO AVE.
Mailing Address - Street 2:SUITE B
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130
Mailing Address - Country:US
Mailing Address - Phone:405-737-4900
Mailing Address - Fax:405-737-3606
Practice Address - Street 1:9230 E RENO AVE
Practice Address - Street 2:SUITE B
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-3337
Practice Address - Country:US
Practice Address - Phone:405-737-4900
Practice Address - Fax:405-737-3606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-25
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK37D2100658OtherCLIA