Provider Demographics
NPI:1356552400
Name:ADVANCED CLINICAL LABORATORIES, LLC
Entity type:Organization
Organization Name:ADVANCED CLINICAL LABORATORIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RODOLFO
Authorized Official - Middle Name:ENRIQUE
Authorized Official - Last Name:TORRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-841-7718
Mailing Address - Street 1:6211 N 35TH AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85017-1415
Mailing Address - Country:US
Mailing Address - Phone:602-841-7718
Mailing Address - Fax:602-841-1695
Practice Address - Street 1:6211 N 35TH AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-1415
Practice Address - Country:US
Practice Address - Phone:602-841-7718
Practice Address - Fax:602-841-1695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ100235Medicare ID - Type UnspecifiedPROVIDER NUMBER