=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154913028
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CEDRUS BIOLABS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2021
-----------------------------------------------------
Last Update Date | 02/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1922 GRASSY BANKS DR
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27610-6472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 984-201-4167
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1922 GRASSY BANKS DR
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27610-6472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 984-201-4167
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR/OWNER
-----------------------------------------------------
Name | TAMMIA ANTOINETTE GATLIN
-----------------------------------------------------
Credential | LPN
-----------------------------------------------------
Telephone | 984-201-4167
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------