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General NPI Number Information
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NPI Number | 1295736841
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Entity Type | Organization
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Legal Business Name | ARCHER CLINIC LABORATORY
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Dates
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Enumeration Date | 08/04/2005
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Last Update Date | 12/31/2007
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Provider Practice Location Address
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Address Line | 400 UNIVERSITY DR SUITE 105
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City | PRESTONSBURG
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State | KY
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Zip | 41653-1080
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Country | US
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Telephone | 606-886-6302
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Fax | 606-886-0597
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Provider Business Mailing Address
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Address Line | 400 UNIVERSITY DR SUITE 105
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City | PRESTONSBURG
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State | KY
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Zip | 41653-1080
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Country | US
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Telephone | 606-886-6302
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Fax | 606-886-0597
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Authorized Official
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Title or Position | LABORATORY MANAGER
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Name | NOEL MARIE GILLIAM
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Credential |
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Telephone | 606-886-6302
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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 | 200111
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License Number State | KY
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