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General NPI Number Information
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NPI Number | 1457531592
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Entity Type | Organization
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Legal Business Name | UNITED DRUG TESTING LABORATORY INC
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Dates
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Enumeration Date | 11/06/2007
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Last Update Date | 11/06/2007
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Provider Practice Location Address
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Address Line | 1010 N. ORCHARD ST SUITE 8
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City | BOISE
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State | ID
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Zip | 83642
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Country | US
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Telephone | 208-331-4097
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Fax | 208-331-4095
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Provider Business Mailing Address
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Address Line | 1010 N. ORCHARD ST SUITE 8
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City | BOISE
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State | ID
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Zip | 83642
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Country | US
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Telephone | 208-331-4097
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Fax | 208-331-4095
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Authorized Official
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Title or Position | LAB DIRECTOR
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Name | MR. KEVIN M ROSE
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Credential | BS
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Telephone | 208-331-4097
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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 | P947
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 13D026723
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License Number State | ID
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