=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104016088
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUEST DIAGNOSTICS CLINICAL LABORATORIES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2007
-----------------------------------------------------
Last Update Date | 02/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11636 ADMINISTRATION DRIVE
-----------------------------------------------------
City | MARYLAND HEIGHTS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63146-3534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-872-6302
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14275 MIDWAY RD STE 400
-----------------------------------------------------
City | ADDISON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75001-3661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax | 610-271-4245
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | LEAH D TIMMERMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-520-2700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 26D0652092
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------