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General NPI Number Information
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NPI Number | 1538413240
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Entity Type | Organization
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Legal Business Name | IMMEDIATE PHLEBOTOMY SERVICE
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Dates
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Enumeration Date | 11/01/2012
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Last Update Date | 11/01/2012
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Provider Practice Location Address
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Address Line | 2002 S MASON RD 1027
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City | KATY
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State | TX
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Zip | 77450-5924
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Country | US
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Telephone | 832-794-7175
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Fax |
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Provider Business Mailing Address
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Address Line | 2002 S MASON RD 1027
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City | KATY
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State | TX
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Zip | 77450-5924
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Country | US
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Telephone | 832-794-7175
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Fax |
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Authorized Official
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Title or Position | C.E.O
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Name | MR. TIMOTHY MARC PETTY
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Credential | CERT. PHLEBOTOMIST
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Telephone | 832-794-7175
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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 | 200310R11
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License Number State | MD
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