MEDICARE: ALLIANCE MEDICAL 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		AZ

General Provider Information

NPI Number	:	1841290806
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALLIANCE MEDICAL LABORATORY, LLC

Provider Business Mailing Address
First Line	:	1764 E ROUTE 66
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86004-5139
Country	:	US
Telephone Number	:	928-773-2575
Fax Number	:	928-214-2680

Provider Business Practice Location Address
First Line	:	1764 E ROUTE 66
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86004-5139
Country	:	US
Telephone Number	:	928-773-2575
Fax Number	:	928-214-2680

Authorized Official
Title or Position	:	CEO
Name	:	MR. JAMES A. PUFFENBERGER
Credential	:
Telephone Number	:	928-779-3366

Provider Enumeration Date	:	07/29/2005
Last Update Date	:	08/22/2020

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