Provider Demographics
NPI:1083066823
Name:SOUTHEAST COMMUNITY LABORATORY NETWORK, LLC
Entity type:Organization
Organization Name:SOUTHEAST COMMUNITY LABORATORY NETWORK, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOHLENDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-663-5631
Mailing Address - Street 1:22240 COUNTY ROAD 39
Mailing Address - Street 2:
Mailing Address - City:LA SALLE
Mailing Address - State:CO
Mailing Address - Zip Code:80645-8727
Mailing Address - Country:US
Mailing Address - Phone:970-663-5631
Mailing Address - Fax:
Practice Address - Street 1:22240 COUNTY ROAD 39
Practice Address - Street 2:
Practice Address - City:LA SALLE
Practice Address - State:CO
Practice Address - Zip Code:80645-8727
Practice Address - Country:US
Practice Address - Phone:970-663-5631
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-05
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory