MEDICARE: WESTERN BIOLOGICAL 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	46D0865144	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	46D0865144	OTHER	UT	CLIA NUMBER

General Provider Information

NPI Number	:	1518084953
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTERN BIOLOGICAL LABORATORY, INC.

Provider Business Mailing Address
First Line	:	2180 E 4500 S
Second Line	:	SUITE 292
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-4434
Country	:	US
Telephone Number	:	801-278-9206
Fax Number	:	801-278-9287

Provider Business Practice Location Address
First Line	:	2180 E 4500 S
Second Line	:	SUITE 292
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-4434
Country	:	US
Telephone Number	:	801-278-9206
Fax Number	:	801-278-9287

Authorized Official
Title or Position	:	LABORATORY DIRECTOR
Name	:	DR. WAYNE R BURT
Credential	:	PH.D.
Telephone Number	:	801-278-9206

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	11/13/2014

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Directions to “WESTERN BIOLOGICAL LABORATORY, INC. ” Practice Location

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