Provider Demographics
NPI:1194968131
Name:MOD LAB
Entity type:Organization
Organization Name:MOD LAB
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:OPPENHEIMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-874-0410
Mailing Address - Street 1:PO BOX 291209
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37229-1209
Mailing Address - Country:US
Mailing Address - Phone:615-874-0410
Mailing Address - Fax:
Practice Address - Street 1:4600 GREENVILLE AVENUE
Practice Address - Street 2:SUITE 240
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-5037
Practice Address - Country:US
Practice Address - Phone:615-874-0410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROST DATA INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-07
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
45D1036151OtherCLIA