MEDICARE: FAIRY WINGS MOBILE PHLEBOTOMY SERVICE LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	291U00000X	Clinical Medical Laboratory
2	332B00000X	Durable Medical Equipment & Medical Supplies
3	343900000X	Non-emergency Medical Transport (VAN)
4	347C00000X	Private Vehicle
5	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1316517329
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAIRY WINGS MOBILE PHLEBOTOMY SERVICE LLC

Provider Business Mailing Address
First Line	:	549 E PASS RD STE J
Second Line	:
City	:	GULFPORT
State	:	MS
Zip	:	39507-3261
Country	:	US
Telephone Number	:	228-284-4176
Fax Number	:	228-284-5724

Provider Business Practice Location Address
First Line	:	549 E PASS RD STE J
Second Line	:
City	:	GULFPORT
State	:	MS
Zip	:	39507-3261
Country	:	US
Telephone Number	:	228-284-5671
Fax Number	:	228-284-5724

Authorized Official
Title or Position	:	OWNER
Name	:	MS. TOMIEKO THREADGILL
Credential	:	PHLEBOT, NCMA, NCMLA
Telephone Number	:	228-284-4176

Provider Enumeration Date	:	06/30/2021
Last Update Date	:	04/11/2023

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