Healthcare Provider Details

I. General information

NPI: 1184472441
Provider Name (Legal Business Name): BLOOD DIAMOND MOBILE LABORATORY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2024
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 RIVER RUSH LN NE
CONYERS GA
30012-6613
US

IV. Provider business mailing address

889 COMMERCE DR SW STE C
CONYERS GA
30094-6624
US

V. Phone/Fax

Practice location:
  • Phone: 770-875-3947
  • Fax:
Mailing address:
  • Phone: 770-762-6019
  • Fax: 770-790-0050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. ROXANN A DOOLING
Title or Position: OWNER/ PHLEBOTOMIST
Credential: CPT, CCMA, CMA, CNA
Phone: 770-875-3947