Healthcare Provider Details

I. General information

NPI: 1437882164
Provider Name (Legal Business Name): SRG HEALTH LABS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2022
Last Update Date: 09/21/2023
Certification Date: 09/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2317 INTERNATIONAL LN STE 114
MADISON WI
53704-3154
US

IV. Provider business mailing address

2317 INTERNATIONAL LN STE 114
MADISON WI
53704-3154
US

V. Phone/Fax

Practice location:
  • Phone: 608-471-4127
  • Fax: 855-316-1039
Mailing address:
  • Phone: 608-471-4127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number
License Number State

VIII. Authorized Official

Name: SADECA GULLENS
Title or Position: CLINICAL LAB DIRECTOR
Credential:
Phone: 608-471-4127