Healthcare Provider Details

I. General information

NPI: 1669391900
Provider Name (Legal Business Name): KM MOBILE LAB ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2026
Last Update Date: 07/11/2026
Certification Date: 07/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 HOSPITAL DR
THOMSON GA
30824-2121
US

IV. Provider business mailing address

5121 WASHINGTON ROAD STE 2 #1019
EVANS GA
30809
US

V. Phone/Fax

Practice location:
  • Phone: 706-843-7275
  • Fax: 706-426-8469
Mailing address:
  • Phone: 706-843-7275
  • Fax: 706-426-8469

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: KYANNA NICOLE MULLEN
Title or Position: OWNER
Credential:
Phone: 762-218-3929