Healthcare Provider Details

I. General information

NPI: 1902552540
Provider Name (Legal Business Name): MA CLINICAL LABORATORY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2022
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3334 FOUNDERS RD
INDIANAPOLIS IN
46268-1333
US

IV. Provider business mailing address

3334 FOUNDERS RD
INDIANAPOLIS IN
46268-1333
US

V. Phone/Fax

Practice location:
  • Phone: 317-220-8499
  • Fax:
Mailing address:
  • Phone: 317-220-8499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MYKESHIA TAYLOR
Title or Position: OWNER
Credential:
Phone: 317-220-8499