Healthcare Provider Details

I. General information

NPI: 1629604046
Provider Name (Legal Business Name): ANCIENT CITY DIAGNOSTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2020
Last Update Date: 03/17/2020
Certification Date: 03/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 SOUTHPARK BLVD STE 206
SAINT AUGUSTINE FL
32086-5179
US

IV. Provider business mailing address

8563 ARGYLE BUSINESS LOOP STE 5
JACKSONVILLE FL
32244-6613
US

V. Phone/Fax

Practice location:
  • Phone: 904-439-3414
  • Fax:
Mailing address:
  • Phone: 904-439-3414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291900000X
TaxonomyMilitary Clinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER EDMONDSON
Title or Position: OWNER
Credential:
Phone: 904-439-3414