Healthcare Provider Details

I. General information

NPI: 1477870772
Provider Name (Legal Business Name): TERRE HAUTE MEDICAL LABORATORY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2010
Last Update Date: 04/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 N 2ND ST
MARSHALL IL
62441-1010
US

IV. Provider business mailing address

634 BEECH ST
TERRE HAUTE IN
47804-2760
US

V. Phone/Fax

Practice location:
  • Phone: 812-244-0100
  • Fax: 812-244-0096
Mailing address:
  • Phone: 812-244-0100
  • Fax: 812-244-0096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number50000920A
License Number StateIN

VIII. Authorized Official

Name: DR. WILLIAM DAVID DEPOND
Title or Position: PRESIDENT/CHIEF MEDICAL OFFICER
Credential: M.D.
Phone: 812-244-0100