Healthcare Provider Details

I. General information

NPI: 1831167196
Provider Name (Legal Business Name): LAB OF PATH, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 12/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 W BEEBE CAPPS EXPY
SEARCY AR
72143-5012
US

IV. Provider business mailing address

1915 W BEEBE CAPPS EXPY
SEARCY AR
72143-5012
US

V. Phone/Fax

Practice location:
  • Phone: 501-268-8175
  • Fax: 501-268-8337
Mailing address:
  • Phone: 501-268-8175
  • Fax: 501-268-8337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMC0253
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberMC0253
License Number StateAR

VIII. Authorized Official

Name: DR. JAMES HENRY GOLLEHER SR.
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 501-268-8175