Provider Demographics
NPI:1780303594
Name:MEDI-LAB DIAGNOSTICS CENTER LLC
Entity type:Organization
Organization Name:MEDI-LAB DIAGNOSTICS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAKIA
Authorized Official - Middle Name:JANEL
Authorized Official - Last Name:GAINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-896-6177
Mailing Address - Street 1:1617 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2834
Mailing Address - Country:US
Mailing Address - Phone:804-896-6177
Mailing Address - Fax:804-451-4739
Practice Address - Street 1:1617 25TH AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2834
Practice Address - Country:US
Practice Address - Phone:804-896-6177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-24
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No207SM0001XAllopathic & Osteopathic PhysiciansMedical GeneticsMolecular Genetic PathologyGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service