Basic Information
| Provider Information | |||||||||
| NPI: | 1417266875 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEXUS LAB, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 92 JOE T PETTY DR | ||||||||
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| City: | RUSSELL SPRINGS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 426428544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708668881 | ||||||||
| FaxNumber: | 2708668849 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 N DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | CAVE CITY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421279546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707923902 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2010 | ||||||||
| LastUpdateDate: | 10/04/2010 | ||||||||
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| AuthorizedOfficialLastName: | BERTRAM | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2708668881 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 200321 | KY | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.