=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649504564
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED LABORATORY SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2009
-----------------------------------------------------
Last Update Date | 10/01/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 N MERIDIAN AVE SUITE 205-S
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73107-6560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-605-2777
-----------------------------------------------------
Fax | 405-602-1235
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 638823
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45263-8823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-605-2777
-----------------------------------------------------
Fax | 405-605-2776
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | MRS. JENNIFER SAMPLES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 405-605-2777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 37D2059506
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------