=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700528858
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTERN LABORATORY ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2022
-----------------------------------------------------
Last Update Date | 04/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2470 EMERALD PL STE C
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27834-5786
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-364-8681
-----------------------------------------------------
Fax | 252-364-8682
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2470 EMERALD PL STE C
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27834-5786
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-364-8681
-----------------------------------------------------
Fax | 252-364-8682
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MRS. TONETTE GODARD
-----------------------------------------------------
Credential | M.S.,BSMT,MLT(ASCP)
-----------------------------------------------------
Telephone | 252-364-8681
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------