MEDICARE: COLBERT LABORATORY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory	09778	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	57244	OTHER	AL	BLUE CROSS

General Provider Information

NPI Number	:	1063406320
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLBERT LABORATORY INC

Provider Business Mailing Address
First Line	:	PO BOX 547
Second Line	:
City	:	RUSSELLVILLE
State	:	AL
Zip	:	35653-0547
Country	:	US
Telephone Number	:	256-332-6602
Fax Number	:	256-332-6690

Provider Business Practice Location Address
First Line	:	128 GUARD ST
Second Line	:
City	:	RUSSELLVILLE
State	:	AL
Zip	:	35653
Country	:	US
Telephone Number	:	256-332-6602
Fax Number	:	256-332-6690

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. GARY L BRILES
Credential	:	MLT
Telephone Number	:	256-332-6602

Provider Enumeration Date	:	09/01/2005
Last Update Date	:	08/01/2007

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