Organization
MODERN LABORATORY INCORPORATED
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. PRASANTA K GHOSE (PRESIDENT)
(630) 933-8101
Entity
Organization
Contact information
Practice address
1793 BLOOMINGDALE RD STE 1, GLENDALE HEIGHTS, IL 60139-3800
(630) 933-8101
(630) 933-8105
Mailing address
1793 BLOOMINGDALE RD STE 1, GLENDALE HEIGHTS, IL 60139-3800
(630) 933-8101
(630) 933-8105
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
Primary
291U00000X
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
14D1079331
CLIA
IL
01
—
216691
PTAN
IL
Enumeration date
03/03/2008
Last updated
09/18/2014
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