Provider Demographics
NPI:1821501800
Name:4 LIFE LAB
Entity Type:Organization
Organization Name:4 LIFE LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARKUETRIC
Authorized Official - Middle Name:D
Authorized Official - Last Name:STRINGFELLOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-278-1319
Mailing Address - Street 1:201 W OLIVE AVE
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-6356
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11709 FRUEHAUF DR STE 103
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-7285
Practice Address - Country:US
Practice Address - Phone:318-278-1319
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-13
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC=========Medicaid