Basic Information
| Provider Information | |||||||||
| NPI: | 1780182949 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NOVUM LABORATORY, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 247 YORK RD | ||||||||
| Address2: | |||||||||
| City: | CARLISLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170133157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8149431271 | ||||||||
| FaxNumber: | 8142454092 | ||||||||
| Practice Location | |||||||||
| Address1: | 313 E PLEASANT VALLEY BLVD | ||||||||
| Address2: | |||||||||
| City: | ALTOONA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 166025512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8149431272 | ||||||||
| FaxNumber: | 8142544092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2018 | ||||||||
| LastUpdateDate: | 01/23/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MAYKO | ||||||||
| AuthorizedOfficialFirstName: | FLORENTINA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8144674055 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.