Provider Demographics
NPI:1003073891
Name:PHOENIX CLINICAL LABS INC
Entity type:Organization
Organization Name:PHOENIX CLINICAL LABS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VIATCHESLAV
Authorized Official - Middle Name:
Authorized Official - Last Name:SAPOZHNIKOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-313-4017
Mailing Address - Street 1:1208 E PASS RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-3403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1208 E PASS RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-3403
Practice Address - Country:US
Practice Address - Phone:228-313-4017
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS25D1084090291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory