=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740048537
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 4K PLUS 1 DIAGNOSTIC LAB CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2024
-----------------------------------------------------
Last Update Date | 03/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7255 TIMBER LEAF BR
-----------------------------------------------------
City | BESSEMER
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35022-3619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-567-6101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7255 TIMBER LEAF BR
-----------------------------------------------------
City | BESSEMER
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35022-3619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-567-6101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | S JOLLY
-----------------------------------------------------
Credential | LPN
-----------------------------------------------------
Telephone | 205-567-6101
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------