Provider Demographics
NPI:1386947844
Name:ST. MARYS LABORATORY
Entity type:Organization
Organization Name:ST. MARYS LABORATORY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERNESTO
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:KUFOY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-463-3500
Mailing Address - Street 1:311 S PINE ST
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-4837
Mailing Address - Country:US
Mailing Address - Phone:337-463-3500
Mailing Address - Fax:337-463-3526
Practice Address - Street 1:311 S PINE ST
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-4837
Practice Address - Country:US
Practice Address - Phone:337-463-3500
Practice Address - Fax:337-463-3526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-06
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA19D1048935291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1666866Medicaid
LA1417118084Medicare PIN
LA1295792596Medicare PIN