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General NPI Number Information
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NPI Number | 1588669667
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Entity Type | Organization
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Legal Business Name | IMA INC LABORATORY
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Dates
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Enumeration Date | 06/16/2005
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Last Update Date | 09/26/2008
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Provider Practice Location Address
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Address Line | 550 S LANDMARK AVE
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City | BLOOMINGTON
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State | IN
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Zip | 47403-3239
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Country | US
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Telephone | 812-331-3406
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Fax | 812-334-0536
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Provider Business Mailing Address
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Address Line | PO BOX 550
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City | BLOOMINGTON
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State | IN
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Zip | 47402-0550
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Country | US
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Telephone | 812-331-3406
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Fax | 812-334-0536
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Authorized Official
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Title or Position | DIRECTOR OF LAB
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Name | TOM F HRISOMALOS
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Credential |
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Telephone | 812-355-3406
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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 | 15D0360681
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License Number State | IN
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