Organization
DAILY LAB SOURCES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. TYRELL TIMOTHY FULWOOD (OWNER)
(704) 953-9432
Entity
Organization
Contact information
Practice address
2838 S ELM EUGENE ST, SUITE 205, GREENSBORO, NC 27406-4410
(704) 953-9432
Mailing address
2838 S ELM EUGENE ST, SUITE 205, GREENSBORO, NC 27406-4410
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
34D2120415
CLIA CERTIFICATE
—
Enumeration date
01/03/2017
Last updated
01/03/2017
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