Provider Demographics
NPI:1295042968
Name:MOBILE STAT LABORATORY
Entity Type:Organization
Organization Name:MOBILE STAT LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CADACIO
Authorized Official - Suffix:
Authorized Official - Credentials:CLS
Authorized Official - Phone:757-962-4863
Mailing Address - Street 1:201 THOROUGHBRED LN APT 307
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-3061
Mailing Address - Country:US
Mailing Address - Phone:757-962-4863
Mailing Address - Fax:757-962-4863
Practice Address - Street 1:201 THOROUGHBRED LN APT 307
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-3061
Practice Address - Country:US
Practice Address - Phone:757-962-4863
Practice Address - Fax:757-962-4863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-01
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1017026291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory