=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649518135
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHLEBOTOMY CONNECTION, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2013
-----------------------------------------------------
Last Update Date | 01/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3806 WEST 86TH ST SUITE B
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-702-2115
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 279 BROOKVIEW DR
-----------------------------------------------------
City | BROWNSBURG
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-702-2115
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL LABORATORY TECHNICIAN
-----------------------------------------------------
Name | MRS. EVE ANNIE NICHOLS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 317-702-2115
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------