MEDICARE: FLORIDA CLINICAL LABORATORY, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory	800025918	FL

General Provider Information

NPI Number	:	1104238302
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLORIDA CLINICAL LABORATORY, INC

Provider Business Mailing Address
First Line	:	481 EDWARD H ROSS DR
Second Line	:
City	:	ELMWOOD PARK
State	:	NJ
Zip	:	07407-3118
Country	:	US
Telephone Number	:	201-791-2600
Fax Number	:	201-791-1941

Provider Business Practice Location Address
First Line	:	5912 BRECKENRIDGE PKWY
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33610-4200
Country	:	US
Telephone Number	:	904-562-1401
Fax Number	:	904-672-1603

Authorized Official
Title or Position	:	COO; EXECUTIVE VP
Name	:	MR. WARREN W ERDMANN
Credential	:
Telephone Number	:	201-791-2600

Provider Enumeration Date	:	05/22/2014
Last Update Date	:	04/11/2018

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