Healthcare Provider Details

I. General information

NPI: 1013678358
Provider Name (Legal Business Name): EXCLUSIVE MOBILE LAB SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2022
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11745 VIRGIL
REDFORD MI
48239-1467
US

IV. Provider business mailing address

11745 VIRGIL
REDFORD MI
48239-1467
US

V. Phone/Fax

Practice location:
  • Phone: 313-613-0171
  • Fax:
Mailing address:
  • Phone: 313-613-0171
  • Fax:

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: NICOLE DARBY
Title or Position: OWNER
Credential: RN
Phone: 313-613-0171