Healthcare Provider Details

I. General information

NPI: 1154035491
Provider Name (Legal Business Name): ON THE ROAD LABS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2023
Last Update Date: 03/11/2026
Certification Date: 03/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 E PASS RD
GULFPORT MS
39507-3236
US

IV. Provider business mailing address

414 E PASS RD
GULFPORT MS
39507-3236
US

V. Phone/Fax

Practice location:
  • Phone: 228-206-4108
  • Fax: 228-206-4109
Mailing address:
  • Phone: 228-206-4108
  • Fax: 228-206-4109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: CRYSTAL THOMPSON
Title or Position: MEDICAL LABORATORY TECHNICIAN
Credential:
Phone: 757-726-7950