MEDICARE: PBL MEDICAL 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	:	1356634125
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PBL MEDICAL LLC

Provider Business Mailing Address
First Line	:	5220 HOOD RD
Second Line	:	SUITE 101
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33418-8910
Country	:	US
Telephone Number	:	561-748-2889
Fax Number	:

Provider Business Practice Location Address
First Line	:	2010 PONCE DE LEON AVE
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33407-6040
Country	:	US
Telephone Number	:	561-748-2889
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT, JUPITER PROF DEVELOPMENT
Name	:	KAREN BARLOW
Credential	:
Telephone Number	:	561-748-2889

Provider Enumeration Date	:	05/26/2011
Last Update Date	:	06/25/2013

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