MEDICARE: COMPUNET CLINICAL LABORATORIES, 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

General Provider Information

NPI Number	:	1790028157
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMPUNET CLINICAL LABORATORIES, LLC

Provider Business Mailing Address
First Line	:	2308 SANDRIDGE DR
Second Line	:
City	:	MORAINE
State	:	OH
Zip	:	45439-1847
Country	:	US
Telephone Number	:	937-297-8253
Fax Number	:	937-297-8254

Provider Business Practice Location Address
First Line	:	2300 MIAMI VALLEY DR
Second Line	:
City	:	CENTERVILLE
State	:	OH
Zip	:	45459-4779
Country	:	US
Telephone Number	:	937-312-1585
Fax Number	:	937-312-1602

Authorized Official
Title or Position	:	CFO
Name	:	MR. JOHN M MANIER
Credential	:
Telephone Number	:	937-297-8202

Provider Enumeration Date	:	04/03/2013
Last Update Date	:	04/03/2013

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