Healthcare Provider Details

I. General information

NPI: 1285610733
Provider Name (Legal Business Name): FORT WAYNE MEDICAL LABORATORY CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2470 LAKE AVE
FT WAYNE IN
46805-5406
US

IV. Provider business mailing address

2470 LAKE AVE
FORT WAYNE IN
46805-5406
US

V. Phone/Fax

Practice location:
  • Phone: 260-424-2195
  • Fax:
Mailing address:
  • Phone: 260-424-2195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number50000070A
License Number StateIN

VIII. Authorized Official

Name: SEUNG S KIM
Title or Position: LABORATORY DIRECTOR
Credential: MD., PHD
Phone: 260-373-3657