MEDICARE: MOBILE MEDICAL ASSISTANT & LABRATORY SERVICE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	305S00000X	Point of Service

General Provider Information

NPI Number	:	1043455207
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOBILE MEDICAL ASSISTANT & LABRATORY SERVICE, LLC

Provider Business Mailing Address
First Line	:	12100 S HIGHWAY 6
Second Line	:	#9101
City	:	SUGAR LAND
State	:	TX
Zip	:	77498-5712
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12100 S. HWY 6
Second Line	:	#9101
City	:	SUGAR LAND
State	:	TX
Zip	:	77498-5712
Country	:	US
Telephone Number	:	281-875-5832
Fax Number	:

Authorized Official
Title or Position	:	OWNER / MANAGER
Name	:	MR. DAMON MONDY
Credential	:
Telephone Number	:	281-875-5832

Provider Enumeration Date	:	12/02/2008
Last Update Date	:	05/05/2011

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