Provider Demographics
NPI:1295147684
Name:CERTUS LABORATORIES, LLC
Entity type:Organization
Organization Name:CERTUS LABORATORIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-842-0274
Mailing Address - Street 1:3827 BIENVILLE BLVD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-5868
Mailing Address - Country:US
Mailing Address - Phone:228-818-0366
Mailing Address - Fax:228-818-0367
Practice Address - Street 1:3827 BIENVILLE BLVD
Practice Address - Street 2:SUITE 10
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5868
Practice Address - Country:US
Practice Address - Phone:228-818-0366
Practice Address - Fax:228-818-0367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-20
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory