Basic Information
| Provider Information | |||||||||
| NPI: | 1811271653 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEXUS LAB 2.0 LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1038 | ||||||||
| Address2: | |||||||||
| City: | FRANKFORT | ||||||||
| State: | KY | ||||||||
| PostalCode: | 406021038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022263858 | ||||||||
| FaxNumber: | 5022239829 | ||||||||
| Practice Location | |||||||||
| Address1: | 1711 S JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385065581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708583341 | ||||||||
| FaxNumber: | 9315251122 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2011 | ||||||||
| LastUpdateDate: | 09/28/2011 | ||||||||
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| AuthorizedOfficialLastName: | BERTRAM | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 2708668881 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PREMIERTOX 2.0, INC. | ||||||||
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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.