MEDICARE: MAGGIES LAB CAB, 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	207ZP0105X	Clinical Pathology/Laboratory Medicine Physician

General Provider Information

NPI Number	:	1598425076
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGGIES LAB CAB, LLC

Provider Business Mailing Address
First Line	:	60 ACOMA BLVD S STE A100
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5998
Country	:	US
Telephone Number	:	928-486-3989
Fax Number	:

Provider Business Practice Location Address
First Line	:	60 ACOMA BLVD S STE A100
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5998
Country	:	US
Telephone Number	:	928-486-3989
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	CASSANDRA KAY KYER
Credential	:	CERTIFIED NP
Telephone Number	:	928-230-5789

Provider Enumeration Date	:	12/23/2021
Last Update Date	:	12/23/2021

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