Basic Information
| Provider Information | |||||||||
| NPI: | 1396928461 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIAGNOSTIC LABORATORY OF OKLAHOMA LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GROVE GENERAL HOSPTIAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 S COLLEGEVILLE RD | ||||||||
| Address2: | |||||||||
| City: | COLLEGEVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194262998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666978378 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1001 E 18TH ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | GROVE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743442907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187862243 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2007 | ||||||||
| LastUpdateDate: | 12/11/2018 | ||||||||
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| AuthorizedOfficialLastName: | SELL | ||||||||
| AuthorizedOfficialFirstName: | LEO | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 4056086298 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 37D0700830 | OK | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 100758750G | 05 | OK | MEDICAID |