Provider Demographics
NPI:1063750842
Name:MYLAB DIAGNOSTICS
Entity type:Organization
Organization Name:MYLAB DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BASIT
Authorized Official - Middle Name:ALI
Authorized Official - Last Name:SYED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-253-6682
Mailing Address - Street 1:448 SOVEREIGN CT STE B
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-4445
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:448 SOVEREIGN CT STE B
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-4445
Practice Address - Country:US
Practice Address - Phone:636-373-1349
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-29
Last Update Date:2013-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOLC1286813291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory