Healthcare Provider Details

I. General information

NPI: 1336838457
Provider Name (Legal Business Name): CB LABORATORY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2023
Last Update Date: 05/12/2023
Certification Date: 05/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 E COURTLAND ST
MORTON IL
61550-9054
US

IV. Provider business mailing address

370 E COURTLAND ST
MORTON IL
61550-9054
US

V. Phone/Fax

Practice location:
  • Phone: 309-291-0899
  • Fax: 309-291-0927
Mailing address:
  • Phone: 309-291-0899
  • Fax: 309-291-0927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MRS. JAYMIE DANIELLE RYAN
Title or Position: CLINICAL LABORATORY SCIENTIST
Credential: CLS (ASCP)
Phone: 309-291-0899