MEDICARE: CHOICE CLINICAL LABORATORY, 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		OK

General Provider Information

NPI Number	:	1700263605
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHOICE CLINICAL LABORATORY, LLC

Provider Business Mailing Address
First Line	:	8210 NATIONAL AVE
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73110-8518
Country	:	US
Telephone Number	:	631-805-4406
Fax Number	:	631-862-5080

Provider Business Practice Location Address
First Line	:	8210 NATIONAL AVE
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73110-8518
Country	:	US
Telephone Number	:	631-805-4406
Fax Number	:	631-862-5080

Authorized Official
Title or Position	:	PRESIDENT / CEO
Name	:	MR. JOHN URALIL
Credential	:
Telephone Number	:	631-805-4406

Provider Enumeration Date	:	04/29/2015
Last Update Date	:	04/29/2015

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