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General NPI Number Information
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NPI Number | 1003997610
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Entity Type | Organization
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Legal Business Name | DTC LABORATORY SERVICES, LLC
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Dates
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Enumeration Date | 10/18/2006
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Last Update Date | 12/07/2012
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Provider Practice Location Address
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Address Line | 1512 20TH AVE
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City | MERIDIAN
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State | MS
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Zip | 39301-4124
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Country | US
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Telephone | 601-484-7740
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 5869
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City | MERIDIAN
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State | MS
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Zip | 39302-5869
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Country | US
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Telephone | 601-484-3257
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | BRIAN L WILKINSON
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Credential | M.D.
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Telephone | 601-484-3257
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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 | 25D0651894
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License Number State | MS
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