Provider Demographics
NPI:1023150786
Name:BROOKSVILLE CLINICAL LABORATORY, INC.
Entity type:Organization
Organization Name:BROOKSVILLE CLINICAL LABORATORY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:R
Authorized Official - Last Name:STUART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-738-4424
Mailing Address - Street 1:PO BOX 348
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39739-0348
Mailing Address - Country:US
Mailing Address - Phone:662-738-4424
Mailing Address - Fax:662-738-4615
Practice Address - Street 1:139 N OLIVER STREET
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:MS
Practice Address - Zip Code:39739
Practice Address - Country:US
Practice Address - Phone:662-738-4424
Practice Address - Fax:662-738-4615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00120679Medicaid