Healthcare Provider Details

I. General information

NPI: 1427702166
Provider Name (Legal Business Name): CONCORDIA HEALTH MOBILE LAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2022
Last Update Date: 02/11/2022
Certification Date: 01/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 HOWLAND ST
BROCKTON MA
02302-2855
US

IV. Provider business mailing address

75 N MAIN ST PMB #6044
RANDOLPH MA
02368
US

V. Phone/Fax

Practice location:
  • Phone: 781-588-0687
  • Fax:
Mailing address:
  • Phone: 774-296-8072
  • Fax:

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: DAPHNEY SIMON-PASCAL
Title or Position: OWNER
Credential: REGISTERED NURSE
Phone: 781-588-0687