Healthcare Provider Details

I. General information

NPI: 1013376151
Provider Name (Legal Business Name): AZ LAB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2016
Last Update Date: 02/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2210 S MILL AVE 8
TEMPE AZ
85282-2153
US

IV. Provider business mailing address

2210 S MILL AVE 8
TEMPE AZ
85282-2153
US

V. Phone/Fax

Practice location:
  • Phone: 623-242-0346
  • Fax:
Mailing address:
  • Phone: 623-242-0346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number4476
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4476
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4476
License Number StateAZ

VIII. Authorized Official

Name: JONNA ELAINE DEMORE
Title or Position: OWNER
Credential:
Phone: 623-242-0346