Provider Demographics
NPI:1063523926
Name:CLINICAL REFERENCE LABORATORY, INC.
Entity type:Organization
Organization Name:CLINICAL REFERENCE LABORATORY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:JERNIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-782-8821
Mailing Address - Street 1:615 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-2200
Mailing Address - Country:US
Mailing Address - Phone:270-782-8821
Mailing Address - Fax:270-842-1820
Practice Address - Street 1:615 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-2200
Practice Address - Country:US
Practice Address - Phone:270-782-8821
Practice Address - Fax:270-842-1820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY200160291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY37901717Medicaid
KY000000112997OtherANTHEM PROVIDER NUMBER
KY4005901Medicare PIN