Provider Demographics
NPI:1568068609
Name:CERTIFIED LAB SERVICES
Entity type:Organization
Organization Name:CERTIFIED LAB SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MEDICAL ASSISTANT
Authorized Official - Phone:480-685-7530
Mailing Address - Street 1:3123 FAIRVIEW AVE E STE 200
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-3051
Mailing Address - Country:US
Mailing Address - Phone:480-685-7530
Mailing Address - Fax:480-900-8853
Practice Address - Street 1:3123 FAIRVIEW AVE E STE 200
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102-3051
Practice Address - Country:US
Practice Address - Phone:480-685-7530
Practice Address - Fax:480-900-8853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-04
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251K00000XAgenciesPublic Health or Welfare
No253Z00000XAgenciesIn Home Supportive Care
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No291U00000XLaboratoriesClinical Medical Laboratory
No305S00000XManaged Care OrganizationsPoint of Service
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ03D2197602OtherUS DEPT OF HEALTH AND HUMAN SERVICES
WAPC61547365OtherPHLEBOTOMIST LICENSE