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General NPI Number Information
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NPI Number | 1003908526
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Entity Type | Organization
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Legal Business Name | FAMILY MEDICAL LAB, INC.
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Dates
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Enumeration Date | 09/29/2006
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Last Update Date | 02/02/2011
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Provider Practice Location Address
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Address Line | 915 E OWEN K GARRIOTT RD SUITE E
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City | ENID
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State | OK
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Zip | 73701-6156
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Country | US
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Telephone | 580-233-2909
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Fax | 580-233-2937
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Provider Business Mailing Address
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Address Line | 915 E OWEN K GARRIOTT RD SUITE E
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City | ENID
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State | OK
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Zip | 73701-6156
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Country | US
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Telephone | 580-233-2909
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Fax | 580-233-2937
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Authorized Official
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Title or Position | OWNER
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Name | MR. STAN LOUCKS
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Credential | MT(ASCP),MA
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Telephone | 580-233-2909
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 37D0472553
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License Number State | OK
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