Provider Demographics
NPI:1285770545
Name:MICRO DIAGNOSTIC LABORATORIES, INC.
Entity type:Organization
Organization Name:MICRO DIAGNOSTIC LABORATORIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MT, ASCP
Authorized Official - Phone:501-316-6337
Mailing Address - Street 1:1200 SALEM RD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72019-8340
Mailing Address - Country:US
Mailing Address - Phone:501-316-6337
Mailing Address - Fax:501-316-4783
Practice Address - Street 1:1200 SALEM RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72019-8340
Practice Address - Country:US
Practice Address - Phone:501-316-6337
Practice Address - Fax:501-316-4783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR18099Medicare PIN