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General NPI Number Information
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NPI Number | 1669431649
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Entity Type | Organization
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Legal Business Name | MID AMERICA CLINICAL LABORATORIES, LLC
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Dates
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Enumeration Date | 03/20/2006
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Last Update Date | 12/11/2018
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Provider Practice Location Address
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Address Line | 1345 UNITY PL SUITE 125
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City | LAFAYETTE
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State | IN
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Zip | 47905-5760
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Country | US
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Telephone | 765-449-1848
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Fax | 765-449-8127
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Provider Business Mailing Address
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Address Line | 2560 N SHADELAND AVE P.O. BOX 19163
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City | INDIANAPOLIS
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State | IN
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Zip | 46219-1705
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Country | US
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Telephone | 317-803-1010
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Fax | 317-803-0186
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Authorized Official
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Title or Position | CFO
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Name | THOMAS KMETZ
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Credential |
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Telephone | 317-803-1010
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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 | 15D0995210
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License Number State | IN
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