Healthcare Provider Details

I. General information

NPI: 1821001330
Provider Name (Legal Business Name): ST JOHNS BIOMEDICAL LABORATORIES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 SOUTHPARK BLVD SUITE A
ST AUGUSTINE FL
32086-4101
US

IV. Provider business mailing address

PO BOX 860206 165 SOUTHPARK BLVD
ST. AUGUSTINE FL
32086-0206
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-5497
  • Fax: 904-824-8257
Mailing address:
  • Phone: 904-824-5497
  • Fax: 904-824-8257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number800001722
License Number StateFL

VIII. Authorized Official

Name: EDWIN OLIVA SIA
Title or Position: DIRECTOR/OWNER
Credential: MD, BCLD(ABB)
Phone: 904-824-5497