MEDICARE: 3 G OPERATING COMPANY, 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	36D0334890	OH

General Provider Information

NPI Number	:	1386800779
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	3 G OPERATING COMPANY, LLC

Provider Business Mailing Address
First Line	:	1919 BISHOP RD
Second Line	:
City	:	WICKLIFFE
State	:	OH
Zip	:	44092-2518
Country	:	US
Telephone Number	:	440-944-9400
Fax Number	:

Provider Business Practice Location Address
First Line	:	1919 BISHOP RD
Second Line	:
City	:	WICKLIFFE
State	:	OH
Zip	:	44092-2518
Country	:	US
Telephone Number	:	440-944-9400
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. BRUCE DASKAL
Credential	:
Telephone Number	:	216-898-8399

Provider Enumeration Date	:	08/05/2008
Last Update Date	:	08/05/2008

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Directions to “3 G OPERATING COMPANY, LLC ” Practice Location

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