Basic Information
| Provider Information | |||||||||
| NPI: | 1033706569 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRO LAB, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 279 | ||||||||
| Address2: | |||||||||
| City: | CABIN CREEK | ||||||||
| State: | WV | ||||||||
| PostalCode: | 250350279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043441623 | ||||||||
| FaxNumber: | 3045569165 | ||||||||
| Practice Location | |||||||||
| Address1: | 3752 TEAYS VALLEY RD STE 1 | ||||||||
| Address2: | |||||||||
| City: | HURRICANE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255269705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043441623 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2020 | ||||||||
| LastUpdateDate: | 12/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3043441623 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 12/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.