Healthcare Provider Details

I. General information

NPI: 1437695731
Provider Name (Legal Business Name): MEDICAL LABORATORY SPECIALTY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2017
Last Update Date: 01/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3636 ST
KINGMAN AZ
86409
US

IV. Provider business mailing address

529 W COLGATE DR
TEMPE AZ
85283-1753
US

V. Phone/Fax

Practice location:
  • Phone: 928-757-3636
  • Fax:
Mailing address:
  • Phone: 480-703-4227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number03D2120368
License Number State

VIII. Authorized Official

Name: JAHAN FERDOUS
Title or Position: DIRECTOR
Credential:
Phone: 480-703-4227