Organization
MID AMERICA CLINICAL LABORATORIES, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. DIANNE Z. VANNESS (C.E.O./GENERAL MANAGER)
(317) 803-0300
Entity
Organization
Contact information
Practice address
1950 W 86TH ST, SUITE 100, INDIANAPOLIS, IN 46260-2076
(317) 803-0330
(317) 334-0709
Mailing address
2560 N SHADELAND AVE, P.O. BOX 19163, INDIANAPOLIS, IN 46219-1705
(317) 803-1010
(317) 803-0186
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
Primary
15D1011663
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
15D1011663
CLIA
IN
05
—
200188040D
—
IN
01
—
7183102
CAP
IN
Enumeration date
03/20/2006
Last updated
09/16/2008
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