Basic Information
| Provider Information | |||||||||
| NPI: | 1518914258 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIME PATHOLOGY LABORATORIES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3464 S WILLOW ST | ||||||||
| Address2: | #604 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802314531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037552900 | ||||||||
| FaxNumber: | 3037550404 | ||||||||
| Practice Location | |||||||||
| Address1: | 6429 MILLER ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | ARVADA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800042810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034327855 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 01/03/2008 | ||||||||
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| AuthorizedOfficialLastName: | NEWCOMB | ||||||||
| AuthorizedOfficialFirstName: | WARD | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7856212041 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | CO | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 60407549 | 05 | CO | MEDICAID |