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General NPI Number Information
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NPI Number | 1265270441
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Entity Type | Organization
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Legal Business Name | IAC DIAGNOSTIC SCREENING LAB
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Dates
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Enumeration Date | 07/19/2024
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Last Update Date | 07/19/2024
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Provider Practice Location Address
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Address Line | 928 GOODMAN RD E STE 202
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City | SOUTHAVEN
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State | MS
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Zip | 38671-8824
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Country | US
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Telephone | 662-715-9623
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Fax |
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Provider Business Mailing Address
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Address Line | 928 GOODMAN RD E STE 202
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City | SOUTHAVEN
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State | MS
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Zip | 38671-8824
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Country | US
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Telephone | 662-715-9623
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MS. BROOKE FARMER
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Credential |
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Telephone | 662-715-9623
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 376J00000X
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Taxonomy Name | Homemaker
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License Number |
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License Number State |
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