Provider Demographics
NPI:1124434352
Name:LIVERLAB INC
Entity type:Organization
Organization Name:LIVERLAB INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDNALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-386-7030
Mailing Address - Street 1:6991 E CAMELBACK RD
Mailing Address - Street 2:STE D-300
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-2432
Mailing Address - Country:US
Mailing Address - Phone:480-386-7030
Mailing Address - Fax:
Practice Address - Street 1:6991 E CAMELBACK RD
Practice Address - Street 2:STE D-300
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-2432
Practice Address - Country:US
Practice Address - Phone:480-386-7030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-09
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ949081Medicaid
AZ949081Medicaid