Healthcare Provider Details

I. General information

NPI: 1336159979
Provider Name (Legal Business Name): PUTNAM CLINICAL LABORATORIES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 02/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 ZEAGLER DR STE 8
PALATKA FL
32177-3826
US

IV. Provider business mailing address

700 ZEAGLER DR STE 8
PALATKA FL
32177-3826
US

V. Phone/Fax

Practice location:
  • Phone: 386-328-4036
  • Fax: 386-328-7397
Mailing address:
  • Phone: 386-328-4036
  • Fax: 386-328-7397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number800008234
License Number StateFL

VIII. Authorized Official

Name: ELIO MADAN
Title or Position: OWNER
Credential: MD
Phone: 386-328-4036