=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528306693
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | METROLAB INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2013
-----------------------------------------------------
Last Update Date | 01/24/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 490 LAKE STREET SUITE 103
-----------------------------------------------------
City | ROSELLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60172-3583
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-882-5125
-----------------------------------------------------
Fax | 630-882-5129
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 490 LAKE STREET SUITE 103
-----------------------------------------------------
City | ROSELLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60172-3583
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-882-5125
-----------------------------------------------------
Fax | 630-882-5129
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. EDUARDO J LADLAD
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 630-882-5125
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------