Provider Demographics
NPI:1447914874
Name:STATE SCIENTIFIC LAB LLC
Entity type:Organization
Organization Name:STATE SCIENTIFIC LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FAHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:GAFFOOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-818-5550
Mailing Address - Street 1:1550 N MANNHEIM RD STE C
Mailing Address - Street 2:
Mailing Address - City:STONE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60165-1300
Mailing Address - Country:US
Mailing Address - Phone:708-223-0457
Mailing Address - Fax:
Practice Address - Street 1:1550 N MANNHEIM RD STE C
Practice Address - Street 2:
Practice Address - City:STONE PARK
Practice Address - State:IL
Practice Address - Zip Code:60165-1300
Practice Address - Country:US
Practice Address - Phone:708-223-0457
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-22
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory