=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780340521
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE MOBILE PHLEBOTOMIST OF GEORGIA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2021
-----------------------------------------------------
Last Update Date | 12/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4600 FARMINGTON RD
-----------------------------------------------------
City | WATKINSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30677-4374
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-340-9566
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4600 FARMINGTON RD
-----------------------------------------------------
City | WATKINSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30677-4374
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-340-9566
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MELISSA S COOPER
-----------------------------------------------------
Credential | CMA/PHLEBOTOMIST
-----------------------------------------------------
Telephone | 67-340-9566
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 202K00000X
-----------------------------------------------------
Taxonomy Name | Phlebology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------