Provider Demographics
NPI:1003997610
Name:DTC LABORATORY SERVICES, LLC
Entity Type:Organization
Organization Name:DTC LABORATORY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-484-3257
Mailing Address - Street 1:PO BOX 5869
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-5869
Mailing Address - Country:US
Mailing Address - Phone:601-484-3257
Mailing Address - Fax:
Practice Address - Street 1:1512 20TH AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4124
Practice Address - Country:US
Practice Address - Phone:601-484-7740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS25D0651894291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSE71605Medicare UPIN
MSB30360Medicare UPIN
MSF54742Medicare UPIN