MEDICARE: RIVER CITY 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

General Provider Information

NPI Number	:	1801499819
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVER CITY LABORATORY, LLC

Provider Business Mailing Address
First Line	:	7130 W MAPLE ST # 230-333
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67209-2187
Country	:	US
Telephone Number	:	816-306-8108
Fax Number	:

Provider Business Practice Location Address
First Line	:	212 S WOODBINE RD # 230-125
Second Line	:
City	:	SAINT JOSEPH
State	:	MO
Zip	:	64506-3447
Country	:	US
Telephone Number	:	816-306-8108
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	ASHLEY TRAYLOR
Credential	:
Telephone Number	:	816-306-8108

Provider Enumeration Date	:	11/20/2020
Last Update Date	:	03/15/2022

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