MEDICARE: 4 LIFE LAB

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	261Q00000X	Clinic/Center		NC

General Provider Information

NPI Number	:	1821501800
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	4 LIFE LAB

Provider Business Mailing Address
First Line	:	201 W OLIVE AVE
Second Line	:
City	:	RUSTON
State	:	LA
Zip	:	71270-6356
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11709 FRUEHAUF DR STE 103
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28273-7285
Country	:	US
Telephone Number	:	318-278-1319
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. MARKUETRIC D STRINGFELLOW
Credential	:
Telephone Number	:	318-278-1319

Provider Enumeration Date	:	11/13/2017
Last Update Date	:	06/20/2018

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Directions to “4 LIFE LAB ” Practice Location

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