Healthcare Provider Details

I. General information

NPI: 1700643764
Provider Name (Legal Business Name): OUTREACH MOBILE LAB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2024
Last Update Date: 03/05/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 WALSHAM WAY
INDIANAPOLIS IN
46254
US

IV. Provider business mailing address

3250 A. WEST 86TH ST #1289
INDIANAPOLIS IN
46268-3605
US

V. Phone/Fax

Practice location:
  • Phone: 317-567-1293
  • Fax:
Mailing address:
  • Phone: 317-567-1293
  • Fax: 317-981-3979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State

VIII. Authorized Official

Name: DEMETRIA BUCKNER
Title or Position: MANAGER
Credential: MA
Phone: 317-567-1293