Provider Demographics
NPI:1538413240
Name:IMMEDIATE PHLEBOTOMY SERVICE
Entity type:Organization
Organization Name:IMMEDIATE PHLEBOTOMY SERVICE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:C.E.O
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:MARC
Authorized Official - Last Name:PETTY
Authorized Official - Suffix:
Authorized Official - Credentials:CERT PHLEBOTOMIST
Authorized Official - Phone:832-794-7175
Mailing Address - Street 1:2002 S MASON RD
Mailing Address - Street 2:1027
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450-5924
Mailing Address - Country:US
Mailing Address - Phone:832-794-7175
Mailing Address - Fax:
Practice Address - Street 1:2002 S MASON RD
Practice Address - Street 2:1027
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-5924
Practice Address - Country:US
Practice Address - Phone:832-794-7175
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-01
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD200310R11291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory