Healthcare Provider Details

I. General information

NPI: 1912914516
Provider Name (Legal Business Name): RENALAB INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

197 INTERSTATE DRIVE SUITE G
RICHLAND MS
39218
US

IV. Provider business mailing address

PO BOX 403096
ATLANTA GA
30384-3096
US

V. Phone/Fax

Practice location:
  • Phone: 615-370-6760
  • Fax: 615-370-6766
Mailing address:
  • Phone: 615-370-6760
  • Fax: 615-370-6766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number25D0883339
License Number StateMS

VIII. Authorized Official

Name: MICHAEL THOMAS BURNEY
Title or Position: COO
Credential:
Phone: 615-370-6740