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General NPI Number Information
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NPI Number | 1801390521
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Entity Type | Organization
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Legal Business Name | LOCAL LAB LLC
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Dates
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Enumeration Date | 03/19/2018
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Last Update Date | 09/12/2018
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Provider Practice Location Address
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Address Line | 8382 N WAYNE DR STE 201
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City | HAYDEN
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State | ID
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Zip | 83835-6028
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Country | US
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Telephone | 208-714-0478
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Fax | 855-485-5234
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Provider Business Mailing Address
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Address Line | 8382 N WAYNE DR STE 201
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City | HAYDEN
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State | ID
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Zip | 83835-6028
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Country | US
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Telephone | 208-714-0478
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Fax | 855-485-5234
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Authorized Official
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Title or Position | MANAGER
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Name | MORGANA SAMORA
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Credential |
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Telephone | 208-929-2234
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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 | 13
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License Number State | ID
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