Healthcare Provider Details

I. General information

NPI: 1659301349
Provider Name (Legal Business Name): RM LAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 10/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 E 25TH ST
IDAHO FALLS ID
83404-7542
US

IV. Provider business mailing address

3910 WASHINGTON PKWY
IDAHO FALLS ID
83404-7596
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-8330
  • Fax: 208-523-3318
Mailing address:
  • Phone: 208-529-8330
  • Fax: 208-884-4611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number13D0520868
License Number StateID

VIII. Authorized Official

Name: VON CROFTS
Title or Position: CEO
Credential:
Phone: 208-523-1122