Provider Demographics
NPI:1043453830
Name:BOSTWICK LABORATORIES, INC.
Entity type:Organization
Organization Name:BOSTWICK LABORATORIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:STEFANELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-512-5200
Mailing Address - Street 1:4355 INNSLAKE DR
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-6742
Mailing Address - Country:US
Mailing Address - Phone:804-967-9225
Mailing Address - Fax:804-239-1954
Practice Address - Street 1:7420 REMCON CIR
Practice Address - Street 2:SUITE J
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-3508
Practice Address - Country:US
Practice Address - Phone:804-967-9225
Practice Address - Fax:804-239-1954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-09
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010062811Medicaid
VA010062811Medicaid
VA190000932Medicare PIN