Healthcare Provider Details

I. General information

NPI: 1366836066
Provider Name (Legal Business Name): FST LAB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2015
Last Update Date: 03/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 ALPINE ST
BRIDGEPORT CT
06610-1727
US

IV. Provider business mailing address

48 ALPINE ST
BRIDGEPORT CT
06610-1727
US

V. Phone/Fax

Practice location:
  • Phone: 203-870-6050
  • Fax: 203-333-9098
Mailing address:
  • Phone: 203-870-6050
  • Fax: 203-333-9098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number07D2023800
License Number StateCT

VIII. Authorized Official

Name: FRITZ MAIGNAN
Title or Position: OWNER
Credential: LPC
Phone: 203-870-6050