Provider Demographics
NPI:1154884575
Name:HEREDILAB, INC
Entity type:Organization
Organization Name:HEREDILAB, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MELODY
Authorized Official - Middle Name:A
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-583-4123
Mailing Address - Street 1:5505 E PIONEER FORK RD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1682
Mailing Address - Country:US
Mailing Address - Phone:801-558-8946
Mailing Address - Fax:
Practice Address - Street 1:1060 E 100 S STE 109
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-4303
Practice Address - Country:US
Practice Address - Phone:801-328-4254
Practice Address - Fax:801-328-9166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE