Healthcare Provider Details

I. General information

NPI: 1659796555
Provider Name (Legal Business Name): MID AMERICA CLINICAL LABORATORIES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2014
Last Update Date: 02/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 HENRY ST
NORTH VERNON IN
47265-1030
US

IV. Provider business mailing address

2560 N SHADELAND AVE
INDIANAPOLIS IN
46219-1705
US

V. Phone/Fax

Practice location:
  • Phone: 812-352-4270
  • Fax: 812-352-4202
Mailing address:
  • Phone: 317-803-1010
  • Fax: 317-803-0186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number15D0686555
License Number StateIN

VIII. Authorized Official

Name: MS. DIANNE Z. VANNESS
Title or Position: CEO/GENERAL MANAGER
Credential:
Phone: 317-803-1010