Provider Demographics
NPI:1629020896
Name:MMDS IDTF LLC
Entity type:Organization
Organization Name:MMDS IDTF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LLOYD
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-230-8093
Mailing Address - Street 1:PO BOX 15268
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28813-0268
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1038 S WILCOX DR
Practice Address - Street 2:SUITE 115
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-5378
Practice Address - Country:US
Practice Address - Phone:423-230-8093
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory