Healthcare Provider Details

I. General information

NPI: 1437424975
Provider Name (Legal Business Name): PATHOLOGISTS DIAGNOSTIC LABORATORY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2012
Last Update Date: 11/24/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 BROOKWOOD BUSINESS PARK DR
WINSTON SALEM NC
27105-4478
US

IV. Provider business mailing address

PO BOX 30369
WINSTON SALEM NC
27130-0369
US

V. Phone/Fax

Practice location:
  • Phone: 336-999-8888
  • Fax: 336-999-8889
Mailing address:
  • Phone: 369-998-8883
  • Fax: 369-998-8889

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: MRS. CARLA N SMITH
Title or Position: CLIENT SERVICES MANAGER
Credential:
Phone: 336-999-8888