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General NPI Number Information
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NPI Number | 1750642112
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Entity Type | Organization
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Legal Business Name | MICROBAC HEALTHCARE SERVICES, LLC
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Dates
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Enumeration Date | 06/01/2012
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Last Update Date | 06/20/2012
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Provider Practice Location Address
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Address Line | 2109 W MARKET ST SUITE 151
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City | JOHNSON CITY
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State | TN
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Zip | 37604-6024
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Country | US
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Telephone | 855-878-6125
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Fax | 423-979-8004
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Provider Business Mailing Address
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Address Line | 2109 W MARKET ST SUITE 151
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City | JOHNSON CITY
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State | TN
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Zip | 37604-6024
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Country | US
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Telephone | 855-878-6125
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Fax | 423-979-8004
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Authorized Official
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Title or Position | MANAGING DIRECTOR
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Name | RILEY MCDONALD
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Credential |
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Telephone | 855-878-6125
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 44D2040965
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License Number State | TN
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