Healthcare Provider Details

I. General information

NPI: 1144049495
Provider Name (Legal Business Name): ELITE-DIAGNOSTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2024
Last Update Date: 10/04/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 HIGHWAY 49 S STE 5B
RICHLAND MS
39218-9438
US

IV. Provider business mailing address

1201 HIGHWAY 49 S STE 5B
RICHLAND MS
39218-9438
US

V. Phone/Fax

Practice location:
  • Phone: 601-665-0360
  • Fax:
Mailing address:
  • Phone: 601-665-0360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name: AKIMMIE LYNN LEWIS
Title or Position: DIRECTOR
Credential: PHLEBOTOMIST
Phone: 601-665-0360