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General NPI Number Information
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NPI Number | 1093462046
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Entity Type | Organization
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Legal Business Name | CAROLINA LAB DIAGNOSTICS, LLC
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Dates
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Enumeration Date | 03/08/2022
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Last Update Date | 03/08/2022
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Provider Practice Location Address
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Address Line | 632 SPRINGDALE RD
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City | STATESVILLE
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State | NC
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Zip | 28677-3432
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Country | US
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Telephone | 704-657-6367
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Fax |
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Provider Business Mailing Address
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Address Line | 632 SPRINGDALE RD
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City | STATESVILLE
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State | NC
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Zip | 28677-3432
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Country | US
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Telephone | 704-657-6367
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JESSICA TILLEY HICKS
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Credential | NURSE PRACTITIONER
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Telephone | 704-657-6367
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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 |
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License Number State |
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