=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124630652
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THREE STRIPE MCCRAY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2020
-----------------------------------------------------
Last Update Date | 08/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2507 E 21ST AVE
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33605-2049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-727-3011
-----------------------------------------------------
Fax | 800-897-5417
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13056 LONG PINE TRL
-----------------------------------------------------
City | CLERMONT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34711-6530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-727-3011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MRS. TASHA MCCRAY
-----------------------------------------------------
Credential | MSN-ED, RN
-----------------------------------------------------
Telephone | 813-727-3011
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------