Provider Demographics
NPI:1528704830
Name:AG SCREENING LAB, LLC
Entity type:Organization
Organization Name:AG SCREENING LAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LOMETRIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-616-8770
Mailing Address - Street 1:108A E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LATTA
Mailing Address - State:SC
Mailing Address - Zip Code:29565-1617
Mailing Address - Country:US
Mailing Address - Phone:843-418-1197
Mailing Address - Fax:843-418-1097
Practice Address - Street 1:108A E MAIN ST
Practice Address - Street 2:
Practice Address - City:LATTA
Practice Address - State:SC
Practice Address - Zip Code:29565-1617
Practice Address - Country:US
Practice Address - Phone:843-418-1197
Practice Address - Fax:843-418-1097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-10
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC42D2257730Medicaid