# FORT WAYNE MEDICAL LABORATORY CORPORATION

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1285610733
- **Authorized official:** SEUNG S KIM MD., PHD (LABORATORY DIRECTOR)
- **Authorized official phone:** (260) 373-3657

## Contact information

- **Practice address:** 2470 LAKE AVE, FT WAYNE, IN 46805-5406
- **Practice address phone:** (260) 424-2195
- **Mailing address:** 2470 LAKE AVE, FORT WAYNE, IN 46805-5406
- **Mailing address phone:** (260) 424-2195

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 246RM2200X | Medical Laboratory Technician | 50000070A | IN | Yes |

## Other

- **Enumeration date:** 12/16/2005
- **Last updated:** 03/01/2012