=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841061314
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PATRIOT DIAGNOSTICS LAB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2024
-----------------------------------------------------
Last Update Date | 01/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 E NINE MILE RD
-----------------------------------------------------
City | HIGHLAND SPRINGS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23075-1833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-659-2757
-----------------------------------------------------
Fax | 804-773-4624
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 E NINE MILE RD
-----------------------------------------------------
City | HIGHLAND SPRINGS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23075-1833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-659-2757
-----------------------------------------------------
Fax | 804-773-4624
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LAB DIRECTOR
-----------------------------------------------------
Name | SHANI TAYLOR DORSEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 804-659-2757
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------