Healthcare Provider Details

I. General information

NPI: 1871355446
Provider Name (Legal Business Name): AG LAB SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 02/19/2024
Certification Date: 02/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 LOG CANOE CIR
STEVENSVILLE MD
21666-2127
US

IV. Provider business mailing address

137 LOG CANOE CIR
STEVENSVILLE MD
21666-2127
US

V. Phone/Fax

Practice location:
  • Phone: 443-249-3405
  • Fax: 443-249-3123
Mailing address:
  • Phone: 443-249-3405
  • Fax: 443-249-3123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ATEEYA GRAY
Title or Position: OWNER
Credential:
Phone: 443-249-3405