=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265892830
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMS MEDICAL LABORATORY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2016
-----------------------------------------------------
Last Update Date | 02/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2900 LEMAY FERRY RD SUITE 205
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63125-3900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-200-6450
-----------------------------------------------------
Fax | 314-200-6451
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2900 LEMAY FERRY RD SUITE 205
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63125-3900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-200-6450
-----------------------------------------------------
Fax | 314-200-6451
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. JUSTIN A CAMILLO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-200-6450
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 26D2045157
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------