=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770943797
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASY MOBILE LABS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2016
-----------------------------------------------------
Last Update Date | 03/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2001 ROSEBUD DR SUITE C
-----------------------------------------------------
City | BILLINGS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59102-6360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-894-2075
-----------------------------------------------------
Fax | 855-522-8726
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2001 ROSEBUD DR SUITE C
-----------------------------------------------------
City | BILLINGS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59102-6360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-894-2075
-----------------------------------------------------
Fax | 855-522-8726
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | KEVIN LAFURGE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 855-562-5227
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 27D2108210
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------