Basic Information
| Provider Information | |||||||||
| NPI: | 1134725690 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAGLE LABS 2 LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 WILLOW PT | ||||||||
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| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394021150 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 4 WILLOW PT | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394021150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018987530 | ||||||||
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| ProviderEnumerationDate: | 12/09/2020 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCDONNIEAL | ||||||||
| AuthorizedOfficialFirstName: | KATIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 6014254893 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0007X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Molecular Genetic Pathology |
No ID Information.