Healthcare Provider Details

I. General information

NPI: 1790976686
Provider Name (Legal Business Name): HEARTLAND LABORATORY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2007
Last Update Date: 03/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 S MAIN ST
CHAFFEE MO
63740-1040
US

IV. Provider business mailing address

221 S MAIN ST
CHAFFEE MO
63740-1040
US

V. Phone/Fax

Practice location:
  • Phone: 573-887-3632
  • Fax: 573-887-3635
Mailing address:
  • Phone: 573-887-3632
  • Fax: 573-887-3635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number34699
License Number StateMO

VIII. Authorized Official

Name: DR. WILLIAM F BLANK
Title or Position: PATHOLOGIST
Credential: M.D.
Phone: 57388736321