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General NPI Number Information
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NPI Number | 1295042968
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Entity Type | Organization
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Legal Business Name | MOBILE STAT LABORATORY
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Dates
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Enumeration Date | 09/01/2010
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Last Update Date | 09/01/2010
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Provider Practice Location Address
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Address Line | 201 THOROUGHBRED LN APT 307
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City | CHESAPEAKE
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State | VA
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Zip | 23320-3061
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Country | US
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Telephone | 757-962-4863
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Fax | 757-962-4863
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Provider Business Mailing Address
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Address Line | 201 THOROUGHBRED LN APT 307
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City | CHESAPEAKE
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State | VA
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Zip | 23320-3061
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Country | US
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Telephone | 757-962-4863
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Fax | 757-962-4863
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Authorized Official
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Title or Position | OWNER/ MANAGER
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Name | MR. NATHAN CADACIO
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Credential | CLS
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Telephone | 757-962-4863
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 1017026
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License Number State | VA
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