Basic Information
| Provider Information | |||||||||
| NPI: | 1821199340 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL EDUCATION ASSISTANCE CORPORATION | ||||||||
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| OtherOrganizationName: | TOXICOLOGY LABORATORY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 699 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376840699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234336050 | ||||||||
| FaxNumber: | 4234336060 | ||||||||
| Practice Location | |||||||||
| Address1: | VA BUILDING 6 | ||||||||
| Address2: | MAGNOLIA AND 5TH STREET | ||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234396424 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 08/22/2018 | ||||||||
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| AuthorizedOfficialLastName: | LEWIS | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4234336050 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEDICAL EDUCATION ASSISTANCE CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 2048 | TN | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 0000002048 | 01 | TN | STATE LICENSE | OTHER | 1235200676 | 01 | LABS GROUP NPI | OTHER |