MEDICARE: KDS MOBILE LAB TESTING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1205571122
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KDS MOBILE LAB TESTING LLC

Provider Business Mailing Address
First Line	:	5521 SW 99TH AVE
Second Line	:
City	:	COOPER CITY
State	:	FL
Zip	:	33328-5705
Country	:	US
Telephone Number	:	863-313-0378
Fax Number	:	866-926-1067

Provider Business Practice Location Address
First Line	:	5521 SW 99TH AVE
Second Line	:
City	:	COOPER CITY
State	:	FL
Zip	:	33328-5705
Country	:	US
Telephone Number	:	863-313-0378
Fax Number	:	866-926-1067

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KAISHIA DOLLAR
Credential	:
Telephone Number	:	786-624-9693

Provider Enumeration Date	:	05/04/2022
Last Update Date	:	05/04/2022

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