Healthcare Provider Details

I. General information

NPI: 1558071993
Provider Name (Legal Business Name): EXQUISITE MOBILE PHLEBOTOMY CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2022
Last Update Date: 11/28/2022
Certification Date: 11/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

458 BRENTWOOD DR APT 6
DAYTONA BEACH FL
32117-4832
US

IV. Provider business mailing address

458 BRENTWOOD DR APT 6
DAYTONA BEACH FL
32117-4832
US

V. Phone/Fax

Practice location:
  • Phone: 863-227-6111
  • Fax:
Mailing address:
  • Phone: 863-227-6111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KATHY KEITH
Title or Position: PHLEBOTOMIST
Credential:
Phone: 863-227-6111