Healthcare Provider Details

I. General information

NPI: 1306343231
Provider Name (Legal Business Name): TIDE LABORATORIES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2018
Last Update Date: 04/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 AIRPORT RD W STE B
FORT PAYNE AL
35968-3315
US

IV. Provider business mailing address

913 AIRPORT RD W STE B
FORT PAYNE AL
35968-3315
US

V. Phone/Fax

Practice location:
  • Phone: 256-845-1261
  • Fax:
Mailing address:
  • Phone: 256-845-1261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number01D2119386
License Number StateAL

VIII. Authorized Official

Name: TREVOR JORDAN CLECKLER
Title or Position: MEMBER
Credential:
Phone: 256-516-4153