MEDICARE: ELITE CLINICAL LABORATORY

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	:	1861039588
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELITE CLINICAL LABORATORY

Provider Business Mailing Address
First Line	:	111 S HUBBARDS LN STE 1
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40207-3937
Country	:	US
Telephone Number	:	502-457-6967
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 S HUBBARDS LN STE 1
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40207-3937
Country	:	US
Telephone Number	:	502-457-6967
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KRISTA PFEIFFER
Credential	:
Telephone Number	:	502-457-6965

Provider Enumeration Date	:	12/02/2019
Last Update Date	:	12/17/2020

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