Basic Information
| Provider Information | |||||||||
| NPI: | 1760743090 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NOVUS LABORATORIES, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 14270 LEE HWY | ||||||||
| Address2: | |||||||||
| City: | BRISTOL | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242024316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2765254606 | ||||||||
| FaxNumber: | 2765254608 | ||||||||
| Practice Location | |||||||||
| Address1: | 14270 LEE HWY | ||||||||
| Address2: | |||||||||
| City: | BRISTOL | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242024316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2765254606 | ||||||||
| FaxNumber: | 2765254608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2012 | ||||||||
| LastUpdateDate: | 05/06/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COULTER | ||||||||
| AuthorizedOfficialFirstName: | TERA | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF LABORATORY OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 2765254606 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | A.S. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 49D2042544 | VA | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 1530278 | 05 | TN | MEDICAID | 49D2042544 | 01 | VA | CLIA | OTHER | 1760743090 | 05 | VA | MEDICAID | 4334814 | 01 | TN | BC/BS | OTHER |