Basic Information
| Provider Information | |||||||||
| NPI: | 1780990564 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN DIAGNOSTIC LABORATORIES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2732 7TH AVE S | ||||||||
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| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352333406 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1450 JONES DAIRY RD | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | AL | ||||||||
| PostalCode: | 355016106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053872113 | ||||||||
| FaxNumber: | 2053872425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2010 | ||||||||
| LastUpdateDate: | 08/31/2010 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | ROSS | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3343585966 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.