MEDICARE: ON THE ROAD LABS, 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	291U00000X	Clinical Medical Laboratory
2	246RP1900X	Phlebotomy Technician

General Provider Information

NPI Number	:	1154035491
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ON THE ROAD LABS, LLC

Provider Business Mailing Address
First Line	:	414 E PASS RD
Second Line	:
City	:	GULFPORT
State	:	MS
Zip	:	39507-3236
Country	:	US
Telephone Number	:	228-206-4108
Fax Number	:	228-206-4109

Provider Business Practice Location Address
First Line	:	414 E PASS RD
Second Line	:
City	:	GULFPORT
State	:	MS
Zip	:	39507-3236
Country	:	US
Telephone Number	:	228-206-4108
Fax Number	:	228-206-4109

Authorized Official
Title or Position	:	MEDICAL LABORATORY TECHNICIAN
Name	:	CRYSTAL THOMPSON
Credential	:
Telephone Number	:	757-726-7950

Provider Enumeration Date	:	01/11/2023
Last Update Date	:	03/11/2026

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