MEDICARE: NORTH COAST CLINICAL 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	N/A

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437130879
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH COAST CLINICAL LABORATORY, INC.

Provider Business Mailing Address
First Line	:	2215 CLEVELAND RD
Second Line	:	SUITE 105
City	:	SANDUSKY
State	:	OH
Zip	:	44870-4485
Country	:	US
Telephone Number	:	419-626-6012
Fax Number	:	419-626-0814

Provider Business Practice Location Address
First Line	:	2215 CLEVELAND RD
Second Line	:	SUITE 105
City	:	SANDUSKY
State	:	OH
Zip	:	44870-4485
Country	:	US
Telephone Number	:	419-626-6012
Fax Number	:	419-626-0814

Authorized Official
Title or Position	:	ADMINISTRATIVE DIRECTOR
Name	:	MR. JACK C. RUNNER
Credential	:	MBA, MT(ASCP), SM(AA
Telephone Number	:	419-626-6012

Provider Enumeration Date	:	11/11/2005
Last Update Date	:	11/24/2014

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