Provider Demographics
NPI:1770211260
Name:PHLEBO MOBILE LLC
Entity type:Organization
Organization Name:PHLEBO MOBILE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR/NCPT
Authorized Official - Prefix:MISS
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:CHARLIE
Authorized Official - Suffix:
Authorized Official - Credentials:NCPT
Authorized Official - Phone:505-330-6953
Mailing Address - Street 1:1305 HUTTON AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-7601
Mailing Address - Country:US
Mailing Address - Phone:505-330-6953
Mailing Address - Fax:505-258-4356
Practice Address - Street 1:1305 HUTTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-7601
Practice Address - Country:US
Practice Address - Phone:505-330-6953
Practice Address - Fax:505-258-4356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-11
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM6872409OtherNEW MEXICO SECRETARY OF STATE CERTIFICATE OF ORGANIZATION
NM76127052Medicaid
NM22-00013318OtherCITY OF FARMINGTON LICENSE
NM1165083OtherNATIONAL CERTIFIED PHLEBOTOMY TECHNICIAN