MEDICARE: WILLIAMS MOBILE PHLEBOTOMY 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	246RP1900X	Phlebotomy Technician

General Provider Information

NPI Number	:	1144713587
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLIAMS MOBILE PHLEBOTOMY SERVICE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 22584
Second Line	:
City	:	ROBBINSDALE
State	:	MN
Zip	:	55422-0584
Country	:	US
Telephone Number	:	763-381-2078
Fax Number	:	612-353-5667

Provider Business Practice Location Address
First Line	:	4810 HUMBOLDT AVE N
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55430-3743
Country	:	US
Telephone Number	:	763-381-2078
Fax Number	:	612-353-5667

Authorized Official
Title or Position	:	OWNER/PHLEBOTOMIST
Name	:	MS. WANDA LATRICE WILLIAMS BAUGH
Credential	:	CMA (AAMA)
Telephone Number	:	763-381-2078

Provider Enumeration Date	:	06/11/2018
Last Update Date	:	06/11/2018

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