Provider Demographics
NPI:1386704310
Name:MEDICAL DIAGNOSTIC LABORATORY INC
Entity type:Organization
Organization Name:MEDICAL DIAGNOSTIC LABORATORY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:PFEIFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-542-3232
Mailing Address - Street 1:1500 E COLLEGE WAY
Mailing Address - Street 2:SUITE A, PMB 276
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-5637
Mailing Address - Country:US
Mailing Address - Phone:360-542-3232
Mailing Address - Fax:360-424-6326
Practice Address - Street 1:409 ELEANOR LANE
Practice Address - Street 2:BUILDING B
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273
Practice Address - Country:US
Practice Address - Phone:360-542-3232
Practice Address - Fax:360-424-6326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMTS-4979291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMTS-4979OtherSTATE LICENSE