Healthcare Provider Details

I. General information

NPI: 1992477673
Provider Name (Legal Business Name): INTEGRATED REGIONAL LABORATORIES PATHOLOGY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2021
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8460 CHAMPIONS GATE BLVD
CHAMPIONS GATE FL
33896-9301
US

IV. Provider business mailing address

PO BOX 741087
ATLANTA GA
30374-1087
US

V. Phone/Fax

Practice location:
  • Phone: 407-530-2420
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL JAMAINE DAVIS
Title or Position: CHIEF OPERATIONS OFFICER
Credential:
Phone: 561-402-4256