=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861012361
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUEST DIAGNOSTICS CLINICAL LABORATORIES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2020
-----------------------------------------------------
Last Update Date | 04/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 129 MITYLENE PARK LANE
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36117-3758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-279-8180
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1201 S COLLEGEVILLE RD
-----------------------------------------------------
City | COLLEGEVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19426-2998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-697-8378
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | CHARLES ALBERT BOWLES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 610-454-6000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------