Provider Demographics
NPI:1275315004
Name:LIFEBLOOM LABS LLC
Entity Type:Organization
Organization Name:LIFEBLOOM LABS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TONEKA
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-665-8319
Mailing Address - Street 1:PO BOX 3622
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28359-3622
Mailing Address - Country:US
Mailing Address - Phone:704-665-8319
Mailing Address - Fax:
Practice Address - Street 1:710 N BROAD ST STE 13
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-9585
Practice Address - Country:US
Practice Address - Phone:704-665-8319
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory