MEDICARE: QUEEN CITY LABS, 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	:	1215701222
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUEEN CITY LABS, LLC

Provider Business Mailing Address
First Line	:	1337 HUNDRED OAKS DR STE A
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28217-4060
Country	:	US
Telephone Number	:	919-874-5033
Fax Number	:

Provider Business Practice Location Address
First Line	:	1337 HUNDRED OAKS DR STE A
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28217-4060
Country	:	US
Telephone Number	:	919-874-5033
Fax Number	:

Authorized Official
Title or Position	:	QUALITY OFFICER
Name	:	DR. ANNA C DAWSEY
Credential	:	PHD
Telephone Number	:	803-351-1791

Provider Enumeration Date	:	11/09/2023
Last Update Date	:	11/09/2023

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