Basic Information
| Provider Information | |||||||||
| NPI: | 1518356435 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMIERTOX 2 0 INC | ||||||||
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| OtherOrganizationName: | PREMIERTOX LAB ALBANY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 538512 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303538512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022263858 | ||||||||
| FaxNumber: | 5022239829 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 N CROSS ST | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 426021416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708662635 | ||||||||
| FaxNumber: | 6063870405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2015 | ||||||||
| LastUpdateDate: | 05/08/2015 | ||||||||
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| AuthorizedOfficialLastName: | KLIPP | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2708668854 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | KY22016860 | KY | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.