=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033239413
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THYROID SPECIALTY LABORATORY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2007
-----------------------------------------------------
Last Update Date | 11/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1636 HEADLAND DR
-----------------------------------------------------
City | FENTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63026-2837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-200-3040
-----------------------------------------------------
Fax | 314-200-3042
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1636 HEADLAND DR
-----------------------------------------------------
City | FENTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63026-2837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-200-3040
-----------------------------------------------------
Fax | 314-200-3042
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FINANCE MANAGER
-----------------------------------------------------
Name | LAURA JANSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-200-3040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 26D0953866
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------