=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225962459
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUXURY DIAGNOSTICS LAB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2026
-----------------------------------------------------
Last Update Date | 06/11/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 126 PROSPECT ST # 214
-----------------------------------------------------
City | PAWTUCKET
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02860-4476
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-457-8084
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 144 OHIO AVE
-----------------------------------------------------
City | PROVIDENCE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02905-4304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-677-6594
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KIELLA KAOMIE SHERIEVES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 401-457-8084
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------