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General NPI Number Information
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NPI Number | 1063831121
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Entity Type | Organization
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Legal Business Name | HIGH DESERT DIAGNOSTIC LABORATORY
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Dates
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Enumeration Date | 04/15/2014
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Last Update Date | 04/15/2014
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Provider Practice Location Address
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Address Line | 1003 DIVISION ST SUITE 5
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City | PRESCOTT
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State | AZ
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Zip | 86301-1657
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Country | US
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Telephone | 928-445-0103
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Fax | 928-445-1032
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Provider Business Mailing Address
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Address Line | 1003 DIVISION ST SUITE 3
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City | PRESCOTT
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State | AZ
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Zip | 86301-1657
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Country | US
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Telephone | 928-445-0103
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Fax | 928-445-1032
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Authorized Official
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Title or Position | PRESIDENT
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Name | THOMAS C FELLOWS
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Credential |
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Telephone | 928-713-1290
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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 | 03D2075971
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License Number State | AZ
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