Provider Demographics
NPI:1306449723
Name:ADVANCED CLINICAL LABORATORY
Entity type:Organization
Organization Name:ADVANCED CLINICAL LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:SHINER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:435-781-0660
Mailing Address - Street 1:1272 W HIGHWAY 40
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-2925
Mailing Address - Country:US
Mailing Address - Phone:435-781-0660
Mailing Address - Fax:435-781-0661
Practice Address - Street 1:1272 W HIGHWAY 40
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-2925
Practice Address - Country:US
Practice Address - Phone:435-781-0660
Practice Address - Fax:435-781-0661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory