Basic Information
| Provider Information | |||||||||
| NPI: | 1730572074 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED DIAGNOSTIC LABS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 36395 | ||||||||
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| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850676395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028899880 | ||||||||
| FaxNumber: | 4803049328 | ||||||||
| Practice Location | |||||||||
| Address1: | 3330 N 2ND ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028899880 | ||||||||
| FaxNumber: | 4803049328 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2015 | ||||||||
| LastUpdateDate: | 03/11/2015 | ||||||||
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| AuthorizedOfficialLastName: | RAJU | ||||||||
| AuthorizedOfficialFirstName: | LAAVAYNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6028899880 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.