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General NPI Number Information
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NPI Number | 1457805533
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Entity Type | Organization
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Legal Business Name | COMMUNITY MEDICAL LABORATORY, LLC
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Dates
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Enumeration Date | 08/06/2016
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Last Update Date | 08/06/2016
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Provider Practice Location Address
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Address Line | 1695 MESQUITE AVE STE 202
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-5687
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Country | US
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Telephone | 928-733-6170
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Fax |
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Provider Business Mailing Address
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Address Line | 1695 MESQUITE AVE STE 202
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-5687
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Country | US
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Telephone | 928-733-6170
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | JULIA A PORTER
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Credential |
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Telephone | 928-733-6170
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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 | 03D2115501
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License Number State |
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