Main Street Clinical Laboratory, Inc

Primary specialty

Clinical Medical LaboratoryTaxonomy code 291U00000X

License

25D2001454 Issued in MS

Legal business name

MAIN STREET CLINICAL LABORATORY, INC

Practice address

8727 Northwest Dr
Southaven, MS 38671-2429

Phone

(662) 510-5432

NPI assigned

Sep 18, 2015

Last updated

Sep 18, 2015By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mark Vines

Title

President

Phone

(662) 288-8532

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1442534400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1442534400000",
    "number": "1881063998",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8727 NORTHWEST DR",
            "city": "SOUTHAVEN",
            "state": "MS",
            "postal_code": "386712429"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8727 NORTHWEST DR",
            "city": "SOUTHAVEN",
            "state": "MS",
            "postal_code": "386712429",
            "telephone_number": "662-510-5432"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MAIN STREET CLINICAL LABORATORY, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-09-18",
        "last_updated": "2015-09-18",
        "status": "A",
        "authorized_official_last_name": "VINES",
        "authorized_official_first_name": "MARK",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "662-288-8532"
    },
    "taxonomies": [
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": "MS",
            "license": "25D2001454",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Clinical Medical Laboratory in Southaven, MS
• Providers in Southaven, MS by specialty
• Clinical Medical Laboratory in Mississippi

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 18, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.