Provider Demographics
NPI:1821781063
Name:1 STIKK MOBLIE LABORATORY LLC
Entity Type:Organization
Organization Name:1 STIKK MOBLIE LABORATORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:R
Authorized Official - Last Name:CLINTON
Authorized Official - Suffix:
Authorized Official - Credentials:RMA,CPT
Authorized Official - Phone:318-512-0170
Mailing Address - Street 1:207 GLENN BRYANT RD
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-5201
Mailing Address - Country:US
Mailing Address - Phone:318-512-0170
Mailing Address - Fax:
Practice Address - Street 1:303 TIMBERLAND DR NE
Practice Address - Street 2:
Practice Address - City:LUDOWICI
Practice Address - State:GA
Practice Address - Zip Code:31316-6669
Practice Address - Country:US
Practice Address - Phone:318-512-0170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service