=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427615996
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOMETOWN DIAGNOSTICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2019
-----------------------------------------------------
Last Update Date | 05/21/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | TRANSLATIONAL RESEARCH CENTER TR311 2500 NORTH STATE STREET
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-415-6564
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 104 W SUNSET DR
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39042-3535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-415-6564
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JUSTIN MCDANIEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 662-415-6564
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------