Healthcare Provider Details

I. General information

NPI: 1235216276
Provider Name (Legal Business Name): BUDE CLINIC LAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 MAIN ST N
BUDE MS
39630
US

IV. Provider business mailing address

PO BOX 445
BUDE MS
39630
US

V. Phone/Fax

Practice location:
  • Phone: 601-384-2394
  • Fax: 601-384-4199
Mailing address:
  • Phone: 601-384-2394
  • Fax: 601-384-2395

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: MARY K LARKIN
Title or Position: OFFICE MANAGER
Credential:
Phone: 601-384-2394