=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255054144
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FULL SERVICE MOBILE LAB CO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2022
-----------------------------------------------------
Last Update Date | 10/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3485 RUFFIN RD APT 1N
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92123-2520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-404-7641
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3485 RUFFIN RD APT 1N
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92123-2520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-404-7641
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARA ELIZABETH JONES
-----------------------------------------------------
Credential | CPT
-----------------------------------------------------
Telephone | 619-404-7641
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------