Basic Information
| Provider Information | |||||||||
| NPI: | 1326283383 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MINERAL AREA LABORATORIES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 78159 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631788159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003541088 | ||||||||
| FaxNumber: | 3148455668 | ||||||||
| Practice Location | |||||||||
| Address1: | 1212 WEBER RD | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 636403325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737564581 | ||||||||
| FaxNumber: | 5737567197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2008 | ||||||||
| LastUpdateDate: | 12/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | DEIDIKER | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 8882759737 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.