=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912283912
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRIUNE LABORATORY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2011
-----------------------------------------------------
Last Update Date | 03/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 325B FIELDS DR
-----------------------------------------------------
City | ABERDEEN
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-944-0595
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 325B FIELDS DR
-----------------------------------------------------
City | ABERDEEN
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-280-8371
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | RHONDA FAYE OUTLAW
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-944-0595
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 34D2029596
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------