Healthcare Provider Details

I. General information

NPI: 1174436661
Provider Name (Legal Business Name): NOVA LAB MOBILE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6615 N 17TH AVE APT 6
PHOENIX AZ
85015-1388
US

IV. Provider business mailing address

6615 N 17TH AVE APT 6
PHOENIX AZ
85015-1388
US

V. Phone/Fax

Practice location:
  • Phone: 480-861-0451
  • Fax:
Mailing address:
  • Phone: 480-861-0451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: NEYDA GONZALEZ PEDRAZA
Title or Position: OWNER
Credential: CPT
Phone: 480-861-0451