Basic Information
| Provider Information | |||||||||
| NPI: | 1093794315 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTH VENTURES OF SOUTHERN ILLINOIS LLC | ||||||||
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| OtherOrganizationName: | TRI-LAB LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 790051 | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631790051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183430640 | ||||||||
| FaxNumber: | 6183430684 | ||||||||
| Practice Location | |||||||||
| Address1: | #1 ST ANTHONYS WAY | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620020340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184654511 | ||||||||
| FaxNumber: | 6184746356 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HUGHES | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6183430639 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.