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General NPI Number Information
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NPI Number | 1003073891
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Entity Type | Organization
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Legal Business Name | PHOENIX CLINICAL LABS INC
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Dates
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Enumeration Date | 05/20/2008
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Last Update Date | 05/20/2008
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Provider Practice Location Address
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Address Line | 1208 E PASS RD
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City | GULFPORT
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State | MS
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Zip | 39507-3403
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Country | US
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Telephone | 228-313-4017
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Fax |
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Provider Business Mailing Address
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Address Line | 1208 E PASS RD
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City | GULFPORT
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State | MS
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Zip | 39507-3403
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | VIATCHESLAV SAPOZHNIKOV
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Credential |
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Telephone | 228-313-4017
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 25D1084090
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License Number State | MS
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