Healthcare Provider Details

I. General information

NPI: 1407678501
Provider Name (Legal Business Name): TENNESSEE MOBILE LABORATORY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2024
Last Update Date: 10/29/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 LAFOLLETTE CIR
PIGEON FORGE TN
37863-3207
US

IV. Provider business mailing address

235 LAFOLLETTE CIR
PIGEON FORGE TN
37863-3207
US

V. Phone/Fax

Practice location:
  • Phone: 865-659-8803
  • Fax:
Mailing address:
  • Phone: 865-659-8803
  • 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 Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: DEANA WILDS
Title or Position: PRESIDENT / CEO
Credential:
Phone: 865-659-8803