=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417601204
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ASSURANCE LAB TESTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2022
-----------------------------------------------------
Last Update Date | 02/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3361 N PENNSYLVANIA ST
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46205-3415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-948-1335
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4961 SEVILLE DR
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46228-2176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-332-8763
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | SHANNON HARRELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 888-948-1335
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 247ZC0005X
-----------------------------------------------------
Taxonomy Name | Clinical Laboratory Director (Non-physician)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------