=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700543659
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TREASURED HEARTS LAB SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2021
-----------------------------------------------------
Last Update Date | 11/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2322 NORWOOD PL
-----------------------------------------------------
City | TAVARES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32778-5102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-272-3390
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 490046
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34749-0046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KAI EVANS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 352-272-3390
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------