Healthcare Provider Details

I. General information

NPI: 1952465288
Provider Name (Legal Business Name): BOSTWICK LABORATORIES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 05/22/2012
Certification Date:
Deactivation Date: 10/06/2011
Reactivation Date: 02/27/2012

III. Provider practice location address

4851 LAKE BROOK DR
GLEN ALLEN VA
23060-9233
US

IV. Provider business mailing address

PO BOX 403751
ATLANTA GA
30384-3751
US

V. Phone/Fax

Practice location:
  • Phone: 804-967-9225
  • Fax: 804-239-1954
Mailing address:
  • Phone: 804-967-9225
  • Fax: 804-239-1954

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: DR. DAVID GRANGER BOSTWICK
Title or Position: CEO, PRESIDENT, CHIEF MED. OFFICER
Credential: MD
Phone: 804-967-9225