MEDICARE: INDEPENDENT HISTOLOGY SERVICE 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		UT

General Provider Information

NPI Number	:	1386728178
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENT HISTOLOGY SERVICE LLC

Provider Business Mailing Address
First Line	:	930 S HOMESTEAD DR
Second Line	:
City	:	WOODLAND HILLS
State	:	UT
Zip	:	84653-2084
Country	:	US
Telephone Number	:	801-423-2334
Fax Number	:	801-221-1899

Provider Business Practice Location Address
First Line	:	930 S HOMESTEAD DR
Second Line	:
City	:	WOODLAND HILLS
State	:	UT
Zip	:	84653-2084
Country	:	US
Telephone Number	:	801-423-2334
Fax Number	:	801-221-1899

Authorized Official
Title or Position	:	OWNER DIRECTOR
Name	:	MR. LESLIE D. HENDRICKSEN
Credential	:	HT ASCP
Telephone Number	:	801-423-2334

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	08/22/2020

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