Provider Demographics
NPI:1053897181
Name:PHOENIXLABORATORY SERVICES LLC
Entity type:Organization
Organization Name:PHOENIXLABORATORY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:ARNEZ
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-485-2233
Mailing Address - Street 1:8345 MOSSYBROOK LN
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-8510
Mailing Address - Country:US
Mailing Address - Phone:678-984-6227
Mailing Address - Fax:
Practice Address - Street 1:6126 PRESTLEY MILL RD STE H
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-5624
Practice Address - Country:US
Practice Address - Phone:678-715-2993
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory