Provider Demographics
NPI:1144476896
Name:BRADSHAW MOUNTAIN DIAGNOSTIC LABORATORY INC
Entity type:Organization
Organization Name:BRADSHAW MOUNTAIN DIAGNOSTIC LABORATORY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:FELLOWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-778-7823
Mailing Address - Street 1:990 WILLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1640
Mailing Address - Country:US
Mailing Address - Phone:928-778-7823
Mailing Address - Fax:928-778-9419
Practice Address - Street 1:203 S CANDY LN
Practice Address - Street 2:SUITE 115-B2
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4120
Practice Address - Country:US
Practice Address - Phone:928-634-0495
Practice Address - Fax:928-634-0565
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRADSHAW MOUNTAIN DIAGNOSTIC LABORATORY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-13
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory