Healthcare Provider Details

I. General information

NPI: 1437130879
Provider Name (Legal Business Name): NORTH COAST CLINICAL LABORATORY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2005
Last Update Date: 11/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 CLEVELAND RD SUITE 105
SANDUSKY OH
44870-4485
US

IV. Provider business mailing address

2215 CLEVELAND RD SUITE 105
SANDUSKY OH
44870-4485
US

V. Phone/Fax

Practice location:
  • Phone: 419-626-6012
  • Fax: 419-626-0814
Mailing address:
  • Phone: 419-626-6012
  • Fax: 419-626-0814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. JACK C. RUNNER
Title or Position: ADMINISTRATIVE DIRECTOR
Credential: MBA, MT(ASCP), SM(AA
Phone: 419-626-6012