Basic Information
| Provider Information | |||||||||
| NPI: | 1265785141 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN ARIZONA CLINICAL LABORATORY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5700 SOUTHWYCK BLVD | ||||||||
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| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436141509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002888325 | ||||||||
| FaxNumber: | 4198665453 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 W SAINT MARYS RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857452623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208723000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2012 | ||||||||
| LastUpdateDate: | 08/27/2015 | ||||||||
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| AuthorizedOfficialLastName: | GILLES | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8002888325 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0006X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology |
No ID Information.