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General NPI Number Information
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NPI Number | 1700555018
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Entity Type | Organization
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Legal Business Name | KINGDOM MOBILE LAB SERVICES LLC
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Dates
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Enumeration Date | 09/09/2021
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Last Update Date | 09/09/2021
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Provider Practice Location Address
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Address Line | 7674 MOUNTAIN CREEK WAY
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City | DOUGLASVILLE
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State | GA
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Zip | 30134-3783
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Country | US
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Telephone | 678-368-2745
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Fax | 678-306-5637
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Provider Business Mailing Address
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Address Line | 7674 MOUNTAIN CREEK WAY
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City | DOUGLASVILLE
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State | GA
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Zip | 30134-3783
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Country | US
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Telephone | 678-368-2745
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Fax | 678-306-5637
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Authorized Official
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Title or Position | OWNER
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Name | KEESHA M MCCLOUD
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Credential |
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Telephone | 678-368-2745
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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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