Provider Demographics
NPI:1386728178
Name:INDEPENDENT HISTOLOGY SERVICE LLC
Entity type:Organization
Organization Name:INDEPENDENT HISTOLOGY SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:HENDRICKSEN
Authorized Official - Suffix:
Authorized Official - Credentials:HT ASCP
Authorized Official - Phone:801-423-2334
Mailing Address - Street 1:930 S HOMESTEAD DR
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:UT
Mailing Address - Zip Code:84653-2084
Mailing Address - Country:US
Mailing Address - Phone:801-423-2334
Mailing Address - Fax:801-221-1899
Practice Address - Street 1:930 S HOMESTEAD DR
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:UT
Practice Address - Zip Code:84653-2084
Practice Address - Country:US
Practice Address - Phone:801-423-2334
Practice Address - Fax:801-221-1899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory