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General NPI Number Information
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NPI Number | 1790932820
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Entity Type | Organization
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Legal Business Name | BRADSHAW MOUNTAIN DIAGNOSTIC LABORATORY INC
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Dates
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Enumeration Date | 08/20/2008
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Last Update Date | 08/20/2008
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Provider Practice Location Address
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Address Line | 7732 EAST FLORENTINE RD
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City | PRESCOTT VALLEY
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State | AZ
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Zip | 86314
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Country | US
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Telephone | 928-772-5889
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Fax | 928-775-5678
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Provider Business Mailing Address
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Address Line | 990 WILLOW CREEK RD
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City | PRESCOTT
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State | AZ
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Zip | 86301-1640
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Country | US
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Telephone | 928-778-7823
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Fax | 928-778-9419
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. TOM FELLOWS
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Credential |
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Telephone | 928-778-7823
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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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