Healthcare Provider Details

I. General information

NPI: 1902678006
Provider Name (Legal Business Name): ELITE MEDICAL LABORATORY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2023
Last Update Date: 10/23/2023
Certification Date: 10/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5435 EMERSON WAY STE 405A-B
INDIANAPOLIS IN
46226-1466
US

IV. Provider business mailing address

5435 EMERSON WAY STE 405A-B
INDIANAPOLIS IN
46226-1466
US

V. Phone/Fax

Practice location:
  • Phone: 317-827-0011
  • Fax:
Mailing address:
  • Phone: 317-827-0011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State

VIII. Authorized Official

Name: MS. RONNISHA SHAQUANA BANKS
Title or Position: OWNER
Credential: CPT
Phone: 779-475-1603