Provider Demographics
NPI:1124474143
Name:ONE LAB MOBILE, LLC
Entity type:Organization
Organization Name:ONE LAB MOBILE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-356-2916
Mailing Address - Street 1:2405 CAINWOOD CT
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-8203
Mailing Address - Country:US
Mailing Address - Phone:770-356-2916
Mailing Address - Fax:770-285-4105
Practice Address - Street 1:2405 CAINWOOD CT
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-8203
Practice Address - Country:US
Practice Address - Phone:770-356-2916
Practice Address - Fax:770-285-4105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-09
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAHO15-01256247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Multi-Specialty