Healthcare Provider Details

I. General information

NPI: 1316517329
Provider Name (Legal Business Name): FAIRY WINGS MOBILE PHLEBOTOMY SERVICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 04/11/2023
Certification Date: 04/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

549 E PASS RD STE J
GULFPORT MS
39507-3261
US

IV. Provider business mailing address

549 E PASS RD STE J
GULFPORT MS
39507-3261
US

V. Phone/Fax

Practice location:
  • Phone: 228-284-5671
  • Fax: 228-284-5724
Mailing address:
  • Phone: 228-284-4176
  • Fax: 228-284-5724

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
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: MS. TOMIEKO THREADGILL
Title or Position: OWNER
Credential: PHLEBOT, NCMA, NCMLA
Phone: 228-284-4176