Healthcare Provider Details

I. General information

NPI: 1831439876
Provider Name (Legal Business Name): HIGHER GROUND LABORATORY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2013
Last Update Date: 02/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17626 DEER FLAT RD
CALDWELL ID
83607-9779
US

IV. Provider business mailing address

17626 DEER FLAT RD
CALDWELL ID
83607-9779
US

V. Phone/Fax

Practice location:
  • Phone: 208-455-5644
  • Fax: 208-620-2376
Mailing address:
  • Phone: 208-455-5644
  • Fax: 208-620-2376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberM-4116
License Number StateID

VIII. Authorized Official

Name: BEATRICE CARROLL
Title or Position: OWNER
Credential:
Phone: 208-440-7009