MEDICARE: WVDHHR/OFFICE OF LABORATORY SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568547651
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WVDHHR/OFFICE OF LABORATORY SERVICES

Provider Business Mailing Address
First Line	:	167 11TH AVE
Second Line	:
City	:	SOUTH CHARLESTON
State	:	WV
Zip	:	25303-1114
Country	:	US
Telephone Number	:	304-558-3530
Fax Number	:

Provider Business Practice Location Address
First Line	:	167 11TH AVE
Second Line	:
City	:	SOUTH CHARLESTON
State	:	WV
Zip	:	25303-1114
Country	:	US
Telephone Number	:	304-558-3530
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. ANDREA MARY LABIK
Credential	:	SC.D.
Telephone Number	:	304-558-3530

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	07/10/2008

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