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General NPI Number Information
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NPI Number | 1679085781
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Entity Type | Organization
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Legal Business Name | STAT LAB SOUTH LLC
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Dates
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Enumeration Date | 10/30/2017
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Last Update Date | 10/30/2017
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Provider Practice Location Address
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Address Line | 333 TEXAS AVE SUITE 1300
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City | SHREVEPORT
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State | LA
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Zip | 71111
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Country | US
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Telephone | 318-618-0298
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Fax | 318-618-0298
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Provider Business Mailing Address
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Address Line | 681 PICKETTS MILL DRIVE
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City | SHREVEPORT
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State | LA
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Zip | 71115
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Country | US
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Telephone | 318-745-5227
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Fax | 318-618-0298
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Authorized Official
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Title or Position | OWNER/OPERATOR
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Name | MRS. CHENETRA J. SMITH
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Credential | RN
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Telephone | 318-745-5227
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 246RP1900X
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Taxonomy Name | Phlebotomy Technician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | RN100044
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License Number State | LA
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