MEDICARE: CROSSROADS LABORATORY, LLC

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	46D2058259	UT

General Provider Information

NPI Number	:	1679948756
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROSSROADS LABORATORY, LLC

Provider Business Mailing Address
First Line	:	6337 S HIGHLAND DR STE 110
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-2107
Country	:	US
Telephone Number	:	801-557-9788
Fax Number	:

Provider Business Practice Location Address
First Line	:	6337 S HIGHLAND DR STE 110
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-2107
Country	:	US
Telephone Number	:	801-557-9788
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. MICHAEL RUSSELL BROWN
Credential	:
Telephone Number	:	801-557-9788

Provider Enumeration Date	:	12/01/2015
Last Update Date	:	12/01/2015

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