Healthcare Provider Details

I. General information

NPI: 1841657681
Provider Name (Legal Business Name): PHYSICIAN'S LABORATORY OF MIDWEST CITY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2016
Last Update Date: 02/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9230 E RENO AVE SUITE B
MIDWEST CITY OK
73130-3337
US

IV. Provider business mailing address

9230 E. RENO AVE. SUITE B
MIDWEST CITY OK
73130
US

V. Phone/Fax

Practice location:
  • Phone: 405-737-4900
  • Fax: 405-737-3606
Mailing address:
  • Phone: 405-737-4900
  • Fax: 405-737-3606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. CARLO LEDESMA
Title or Position: LABORATORY DIRECTOR
Credential: MT,ASAP,MS
Phone: 405-737-4900