MEDICARE: STATLAB DIAGNOSTICS, 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

General Provider Information

NPI Number	:	1790387223
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATLAB DIAGNOSTICS, LLC

Provider Business Mailing Address
First Line	:	3810 IRVING ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80211
Country	:	US
Telephone Number	:	303-756-1020
Fax Number	:

Provider Business Practice Location Address
First Line	:	3810 IRVING ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80211
Country	:	US
Telephone Number	:	303-756-1020
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	SHIDEH KERMAN
Credential	:
Telephone Number	:	303-547-2100

Provider Enumeration Date	:	11/10/2020
Last Update Date	:	02/10/2023

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