Basic Information
| Provider Information | |||||||||
| NPI: | 1811472186 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NANI LAB LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 W 22ND ST STE 300 | ||||||||
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| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605234071 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 7836 W JEFFERSON BLVD STE 10 | ||||||||
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| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468044165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604943484 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2018 | ||||||||
| LastUpdateDate: | 10/02/2018 | ||||||||
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| AuthorizedOfficialLastName: | O'DEA | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6309745225 | ||||||||
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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.