=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629073168
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPUNET CLINICAL LABORATORIES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2005
-----------------------------------------------------
Last Update Date | 10/09/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1888 W MAIN ST
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45373-2304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-296-0844
-----------------------------------------------------
Fax | 937-297-8232
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2308 SANDRIDGE DR
-----------------------------------------------------
City | MORAINE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45439-1847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-296-0844
-----------------------------------------------------
Fax | 937-297-8232
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO/VP FINANCE
-----------------------------------------------------
Name | MR. JOHN M MANIER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 937-297-8202
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 36D0348736
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------