=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194109504
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASY MOBILE LABS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2015
-----------------------------------------------------
Last Update Date | 07/15/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8417 CROSSLAND LOOP
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36117-8485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-562-5227
-----------------------------------------------------
Fax | 855-522-8726
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 149 SPACE PARK S
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37211-3123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-562-5227
-----------------------------------------------------
Fax | 855-522-8726
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. KEVIN LAFURGE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 360-852-0302
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------