Provider Demographics
NPI:1316517329
Name:FAIRY WINGS MOBILE PHLEBOTOMY SERVICE LLC
Entity type:Organization
Organization Name:FAIRY WINGS MOBILE PHLEBOTOMY SERVICE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TOMIEKO
Authorized Official - Middle Name:
Authorized Official - Last Name:THREADGILL
Authorized Official - Suffix:
Authorized Official - Credentials:PHLEBOT, NCMA, NCMLA
Authorized Official - Phone:228-284-4176
Mailing Address - Street 1:549 E PASS RD STE J
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-3261
Mailing Address - Country:US
Mailing Address - Phone:228-284-4176
Mailing Address - Fax:228-284-5724
Practice Address - Street 1:549 E PASS RD STE J
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-3261
Practice Address - Country:US
Practice Address - Phone:228-284-5671
Practice Address - Fax:228-284-5724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-30
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No291U00000XLaboratoriesClinical Medical Laboratory
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle