=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013376151
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AZ LAB, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/17/2016
-----------------------------------------------------
Last Update Date | 02/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2210 S MILL AVE 8
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85282-2153
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-242-0346
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2210 S MILL AVE 8
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85282-2153
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-242-0346
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JONNA ELAINE DEMORE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 623-242-0346
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 4476
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 4476
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207KA0200X
-----------------------------------------------------
Taxonomy Name | Allergy Physician
-----------------------------------------------------
License Number | 4476
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------