Healthcare Provider Details

I. General information

NPI: 1174859714
Provider Name (Legal Business Name): MAIN STREET CLINICAL LABORATORY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2009
Last Update Date: 09/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8727 NORTHWEST DR
SOUTHAVEN MS
38671-2429
US

IV. Provider business mailing address

12075 E 45TH AVE SUITE 600
DENVER CO
80239-3123
US

V. Phone/Fax

Practice location:
  • Phone: 303-371-0073
  • Fax:
Mailing address:
  • Phone: 303-371-0073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JAY SCHRYVER
Title or Position: VP OF OPERATIONS
Credential:
Phone: 303-371-0073