=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265685705
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MILLENNIUM LABORATORY CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2008
-----------------------------------------------------
Last Update Date | 10/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3362 SIX FORKS RD
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27609-7233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-785-2933
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9800 TWIN LAKES PKWY STE B
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28269-6602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-578-5372
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATIONS OFFICER
-----------------------------------------------------
Name | MR. KYLE D STEPHENS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-578-5372
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 34D1090483
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------