Healthcare Provider Details

I. General information

NPI: 1376116111
Provider Name (Legal Business Name): ELITE BIOMEDICAL LAB SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 07/20/2021
Certification Date: 07/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15202 NW 147TH DR STE 600
ALACHUA FL
32615-5333
US

IV. Provider business mailing address

15202 NW 147TH DR STE 600
ALACHUA FL
32615-5333
US

V. Phone/Fax

Practice location:
  • Phone: 386-588-3230
  • Fax: 888-480-7977
Mailing address:
  • Phone: 386-588-3230
  • Fax: 888-480-7977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MARJILLIAN WILLIAMS
Title or Position: PRESIDENT
Credential: BS,MT
Phone: 386-965-0313