Healthcare Provider Details

I. General information

NPI: 1548347438
Provider Name (Legal Business Name): CROSS LANES FAMILY PRACTICE, INC. (LAB)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5480 BIG TYLER RD
CROSS LANES WV
25313-1116
US

IV. Provider business mailing address

5480 BIG TYLER RD
CROSS LANES WV
25313-1116
US

V. Phone/Fax

Practice location:
  • Phone: 304-776-2409
  • Fax: 304-776-2023
Mailing address:
  • Phone: 304-776-2409
  • Fax: 304-776-2023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: GREGORY C STONESTREET
Title or Position: PRESIDENT
Credential: MD
Phone: 304-776-2409