Provider Demographics
NPI:1265789200
Name:MHG OUTPATIENT LAB LLC
Entity type:Organization
Organization Name:MHG OUTPATIENT LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GUY
Authorized Official - Middle Name:DARRON
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:573-747-1510
Mailing Address - Street 1:560 W PINE ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-1426
Mailing Address - Country:US
Mailing Address - Phone:573-747-0544
Mailing Address - Fax:573-747-1962
Practice Address - Street 1:560 W PINE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1426
Practice Address - Country:US
Practice Address - Phone:573-747-0544
Practice Address - Fax:573-747-1962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory