Healthcare Provider Details

I. General information

NPI: 1275536195
Provider Name (Legal Business Name): TERRE HAUTE MEDICAL LABORATORY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 12/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1606 N 7TH STREET
TERRE HAUTE IN
47804-2706
US

IV. Provider business mailing address

PO BOX 9359 634 BEECH STREET
TERRE HAUTE IN
47808-9359
US

V. Phone/Fax

Practice location:
  • Phone: 812-244-0100
  • Fax: 812-232-1517
Mailing address:
  • Phone: 812-244-0100
  • Fax: 812-232-1517

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: MR. WILLIAM D. DEPOND
Title or Position: PRESIDENT AND CHIEF MEDICAL OFFICER
Credential: M.D.
Phone: 812-244-0100