=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629446968
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROSEMOND SCHOOL OF PHLEBOTOMY CLINICAL LABORATORY-RESEARCH & TESTING,
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2015
-----------------------------------------------------
Last Update Date | 09/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1425 S PURPERA
-----------------------------------------------------
City | GONZALES
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-644-2422
-----------------------------------------------------
Fax | 225-644-2428
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 355
-----------------------------------------------------
City | BRITTANY
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70718-0355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-644-2422
-----------------------------------------------------
Fax | 225-644-2428
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MRS. ORA JONES
-----------------------------------------------------
Credential | CML
-----------------------------------------------------
Telephone | 225-644-2422
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | CLP-L02556-LAB
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------