=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023622305
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOLECULAR AND DIAGNOSTIC TESTING LABS OF AMERICA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2020
-----------------------------------------------------
Last Update Date | 01/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1529 CLIFF GOOKIN BLVD
-----------------------------------------------------
City | TUPELO
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38801-6401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-412-8934
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1529 CLIFF GOOKIN BLVD
-----------------------------------------------------
City | TUPELO
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38801-6401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-421-8934
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOSEPH CAMPBELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 662-266-2217
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------