=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396076659
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | USACCUSCREEN, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2010
-----------------------------------------------------
Last Update Date | 01/26/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3365 CYPRESS MILL RD SUITE 9 & 10
-----------------------------------------------------
City | BRUNSWICK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31520-2865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-267-9000
-----------------------------------------------------
Fax | 912-267-9028
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3408 TROUT ST
-----------------------------------------------------
City | BRUNSWICK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31520-3622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-267-9000
-----------------------------------------------------
Fax | 912-267-9028
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | DR. MICHAEL JAMES LUPI
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 912-267-9000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------