Healthcare Provider Details

I. General information

NPI: 1316196264
Provider Name (Legal Business Name): MEDLAB792
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2008
Last Update Date: 09/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

792 STATE ST
BANGOR ME
04401-5610
US

IV. Provider business mailing address

792 STATE ST
BANGOR ME
04401-5610
US

V. Phone/Fax

Practice location:
  • Phone: 207-947-6508
  • Fax: 207-941-8342
Mailing address:
  • Phone: 207-947-6508
  • Fax: 207-941-8342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number20D0681466
License Number StateME

VIII. Authorized Official

Name: DR. VANCE A ALOUPIS
Title or Position: PRESIDENT
Credential: MD
Phone: 207-947-6805