Healthcare Provider Details

I. General information

NPI: 1942105952
Provider Name (Legal Business Name): EMPIRE MOBILE LAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1969 GLENN RD
GASTON SC
29053-9393
US

IV. Provider business mailing address

1969 GLENN RD
GASTON SC
29053-9393
US

V. Phone/Fax

Practice location:
  • Phone: 803-239-7513
  • Fax:
Mailing address:
  • Phone: 803-239-7513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. AMANDA SCOTT
Title or Position: DIRECTOR
Credential:
Phone: 803-239-7513