Basic Information
| Provider Information | |||||||||
| NPI: | 1700030756 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ESSEX HEALTHCARE CORP | ||||||||
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| OtherOrganizationName: | ST. MARY'S LIVING CENTER-LAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1209 INDIANA AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT MARYS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458851310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193947611 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1209 INDIANA AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT MARYS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458851310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193947611 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2008 | ||||||||
| LastUpdateDate: | 11/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | LOCKHART | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 6144160600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ESSEX HEALTH CARE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 36D0656530 | OH | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.