Healthcare Provider Details

I. General information

NPI: 1154326668
Provider Name (Legal Business Name): TWIN RIVERS MEDICAL LABORATORY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 08/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 W. BROADWAY
LOGANSPORT IN
46947-2978
US

IV. Provider business mailing address

902 W. BROADWAY
LOGANSPORT IN
46947-2978
US

V. Phone/Fax

Practice location:
  • Phone: 574-739-0004
  • Fax: 574-739-0105
Mailing address:
  • Phone: 574-739-0004
  • Fax: 574-739-0105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. CONNIE LOUELLEN BOSTIC
Title or Position: PRESIDENT
Credential: RMT
Phone: 574-739-0004