Organization
MAIN STREET CLINICAL LABORATORY, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARK VINES (PRESIDENT)
(662) 288-8532
Entity
Organization
Contact information
Practice address
8727 NORTHWEST DR, SOUTHAVEN, MS 38671-2429
(662) 510-5432
Mailing address
8727 NORTHWEST DR, SOUTHAVEN, MS 38671-2429
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
Primary
25D2001454
MS
Other
Enumeration date
09/18/2015
Last updated
09/18/2015
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