=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649437435
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHOICE LAB INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2008
-----------------------------------------------------
Last Update Date | 05/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1572 EDMUND AVE SUITE 101
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55104-2343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-434-5508
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1572 EDMUND AVE SUITE 101
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55104-2343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LEONARD D STAMPANETTI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 651-434-5508
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 24D1084147
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------