Healthcare Provider Details

I. General information

NPI: 1205173770
Provider Name (Legal Business Name): DUCKWORTH LABORATORIES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2013
Last Update Date: 01/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 UNION AVE SUITE 300
MEMPHIS TN
38104-6638
US

IV. Provider business mailing address

1211 UNION AVE SUITE 300
MEMPHIS TN
38104-6638
US

V. Phone/Fax

Practice location:
  • Phone: 901-725-7551
  • Fax: 901-725-9721
Mailing address:
  • Phone: 901-725-7551
  • Fax: 901-725-9721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number3282
License Number StateTN

VIII. Authorized Official

Name: DOROTHY L BLACK
Title or Position: COMPLIANCE OFFICETR
Credential: CHCO
Phone: 901-725-7551