| Organization Name: | FORT WAYNE MEDICAL LABORATORY CORPORATION |
| NPI Number: | 1285610733 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | SEUNG S KIM (LABORATORY DIRECTOR) |
| Mailing Address: | 2470 Lake Ave Ft Wayne |
| State: | IN US |
| Postal Code: | 468055406 |
| Phone Number: | 2604242195 |
| Fax Number: | |
| NPI Enumeration Date: | 12/16/2005 |
| NPI Last Update Date: | 03/01/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 246RM2200X |
| License Number: | 50000070A |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IN |
| Taxonomy Type: | Technologists, Technicians & Other Technical Service Providers |
| Taxonomy Classification: | Technician, Pathology |
| Taxonomy Specialization: | Medical Laboratory |
| Taxonomy Definition: | |