Basic Information
| Provider Information | |||||||||
| NPI: | 1437155744 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HURON LABORATORY SVC PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 E 10TH ST | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553874552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524429770 | ||||||||
| FaxNumber: | 9524423620 | ||||||||
| Practice Location | |||||||||
| Address1: | 172 4TH ST SE | ||||||||
| Address2: | |||||||||
| City: | HURON | ||||||||
| State: | SD | ||||||||
| PostalCode: | 573502510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053536200 | ||||||||
| FaxNumber: | 9524423620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 12/29/2016 | ||||||||
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| AuthorizedOfficialLastName: | VAN WINKLE | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6059406410 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0101X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology |
ID Information
| ID | Type | State | Issuer | Description | 220023870 | 01 | SD | RAILROAD MEDICARE | OTHER | 0005771 | 01 | SD | BLUE CROSS SD | OTHER | 6600320 | 05 | SD | MEDICAID |