Provider Demographics
NPI:1588194054
Name:MID STAR LAB INC
Entity type:Organization
Organization Name:MID STAR LAB INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KARI
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:913-369-8734
Mailing Address - Street 1:1701 COMMERCE RD
Mailing Address - Street 2:
Mailing Address - City:TONGANOXIE
Mailing Address - State:KS
Mailing Address - Zip Code:66086-5369
Mailing Address - Country:US
Mailing Address - Phone:913-369-8734
Mailing Address - Fax:
Practice Address - Street 1:5480 MAIN ST STE 104
Practice Address - Street 2:
Practice Address - City:DEL CITY
Practice Address - State:OK
Practice Address - Zip Code:73115-5518
Practice Address - Country:US
Practice Address - Phone:913-369-8734
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies