MEDICARE: DIAGNOSTIC LABORATORY OF OKLAHOMA LLC

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	37D0656554	OK

General Provider Information

NPI Number	:	1215049747
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIAGNOSTIC LABORATORY OF OKLAHOMA LLC

Provider Business Mailing Address
First Line	:	1201 S COLLEGEVILLE RD
Second Line	:
City	:	COLLEGEVILLE
State	:	PA
Zip	:	19426-2998
Country	:	US
Telephone Number	:	866-697-8378
Fax Number	:

Provider Business Practice Location Address
First Line	:	900 N PORTER AVE
Second Line	:	STE 109
City	:	NORMAN
State	:	OK
Zip	:	73071-6426
Country	:	US
Telephone Number	:	405-329-5467
Fax Number	:

Authorized Official
Title or Position	:	CONTROLLER
Name	:	LEO SELL
Credential	:
Telephone Number	:	405-608-6298

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	12/11/2018

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