Healthcare Provider Details

I. General information

NPI: 1033030580
Provider Name (Legal Business Name): RGC DIAGNOSTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 N SCENIC HWY
LAKE WALES FL
33853-3208
US

IV. Provider business mailing address

718 N SCENIC HWY
LAKE WALES FL
33853-3208
US

V. Phone/Fax

Practice location:
  • Phone: 863-331-7450
  • Fax:
Mailing address:
  • Phone: 863-331-7450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateNULL

VIII. Authorized Official

Name: DEMIKA GARDNER
Title or Position: OWNER
Credential:
Phone: 863-331-7450