Healthcare Provider Details

I. General information

NPI: 1740978576
Provider Name (Legal Business Name): SOUTHERN MARYLAND MOBILE LAB SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2023
Last Update Date: 04/28/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3965 SAINT CHARLES PKWY
WALDORF MD
20602-2683
US

IV. Provider business mailing address

3828 LAKEWOOD PL
WALDORF MD
20602-1429
US

V. Phone/Fax

Practice location:
  • Phone: 240-538-8571
  • Fax: 240-607-7229
Mailing address:
  • Phone: 240-929-5944
  • Fax: 240-607-7229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: TEAIRA GENEVA MILBURN
Title or Position: CEO
Credential:
Phone: 240-925-9449