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General NPI Number Information
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NPI Number | 1760922660
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Entity Type | Organization
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Legal Business Name | PHOENIX DIAGNOSTIC LABS
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Dates
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Enumeration Date | 02/27/2017
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Last Update Date | 02/27/2017
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Provider Practice Location Address
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Address Line | 187 SAINT PAUL ST STE 3B-1
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City | BURLINGTON
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State | VT
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Zip | 05401-4689
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Country | US
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Telephone | 802-745-7347
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Fax |
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Provider Business Mailing Address
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Address Line | 187 SAINT PAUL ST STE 3B-1
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City | BURLINGTON
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State | VT
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Zip | 05401-4689
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | LABORATORY DIRECTOR
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Name | KAILA J HANOVER
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Credential |
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Telephone | 802-745-7347
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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 |
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License Number State |
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