Healthcare Provider Details

I. General information

NPI: 1942995618
Provider Name (Legal Business Name): BLUDBORN LABS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 04/10/2023
Certification Date: 04/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

258 W WALNUT ST
JESUP GA
31545-1331
US

IV. Provider business mailing address

258 W WALNUT ST
JESUP GA
31545-1331
US

V. Phone/Fax

Practice location:
  • Phone: 912-202-6179
  • Fax:
Mailing address:
  • Phone: 912-202-6179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State

VIII. Authorized Official

Name: ANGELA DARDEN-RIVERS
Title or Position: CEO
Credential: CPT
Phone: 912-202-6179