MEDICARE: PEARL DIAGNOSTIC LABORATORY, LLC

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

General Provider Information

NPI Number	:	1215544549
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEARL DIAGNOSTIC LABORATORY, LLC

Provider Business Mailing Address
First Line	:	2202 BUECHEL AVE STE 105D
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40218-2672
Country	:	US
Telephone Number	:	502-814-4074
Fax Number	:	502-814-4073

Provider Business Practice Location Address
First Line	:	2202 BUECHEL AVE STE 105D
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40218-2672
Country	:	US
Telephone Number	:	502-814-4074
Fax Number	:	502-814-4073

Authorized Official
Title or Position	:	CEO
Name	:	OSAWARU OMORUYI
Credential	:	MD
Telephone Number	:	502-777-4301

Provider Enumeration Date	:	09/30/2020
Last Update Date	:	09/28/2022

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