NPIViewer - Provider NPI 1396321022

NPI:	1396321022
Name:	SPECTRA LABORATORIES INC
Entity type:	Organization
Organization Name:	SPECTRA LABORATORIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:	PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:	CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:	CHURCHILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:	781-699-2306
Mailing Address - Street 1:	1280 STATELINE RD E
Mailing Address - Street 2:
Mailing Address - City:	SOUTHAVEN
Mailing Address - State:	MS
Mailing Address - Zip Code:	38671-9486
Mailing Address - Country:	US
Mailing Address - Phone:	877-334-0021
Mailing Address - Fax:	800-716-5539
Practice Address - Street 1:	1280 STATELINE RD E
Practice Address - Street 2:
Practice Address - City:	SOUTHAVEN
Practice Address - State:	MS
Practice Address - Zip Code:	38671-9486
Practice Address - Country:	US
Practice Address - Phone:	877-334-0021
Practice Address - Fax:	800-716-5539
EIN:	<UNAVAIL>
Is Organization Subpart?:	No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:	2021-03-23
Last Update Date:	2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:

Primary?	Code	Type	Classification	Specialization
Yes	291U00000X	Laboratories	Clinical Medical Laboratory

State	Identifier ID	ID Type
MS	08652003	Medicaid
AL	1396321022	Medicaid
MT	1396321022	Medicaid
AK	1396321022	Medicaid
MI	1396321022	Medicaid
MN	1396321022	Medicaid
AR	273863709	Medicaid
UT	4092925	Medicaid
OH	0468700	Medicaid
ME	1396321022	Medicaid
SD	1396321022	Medicaid
ID	1396321022	Medicaid
FL	112006800	Medicaid
CT	1396321022	Medicaid
WA	2203364	Medicaid
LA	2574035	Medicaid
TX	440392501	Medicaid
AS	649049-OC	Medicaid
VT	6709267	Medicaid
KY	7100777440	Medicaid
CO	9000198819	Medicaid
NM	97820288	Medicaid
TN	Q069018	Medicaid
GA	003263868A	Medicaid
KS	100245690C	Medicaid
GU	GBB	Medicaid
NC	1396321022	Medicaid
CA	1396321022	Medicaid
NE	10026890900	Medicaid
AZ	103860	Medicaid
HI	1396321022	Medicaid
WY	209158500	Medicaid
SC	L00865	Medicaid
DC	013403892	Medicaid
WI	1396321022	Medicaid
IA	1396321022	Medicaid
IL	1396321022	Medicaid
WV	1396321022	Medicaid
MO	700104418	Medicaid