=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932850609
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOOD STICK LABORATORY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2022
-----------------------------------------------------
Last Update Date | 01/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4069 TAHOE DRIVE
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-835-3421
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11432 MUTZ CIR
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46229-2246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-835-3421
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | REBBI COE
-----------------------------------------------------
Credential | LPN
-----------------------------------------------------
Telephone | 317-835-3421
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------