Healthcare Provider Details

I. General information

NPI: 1932338100
Provider Name (Legal Business Name): HOMEFRONT DIAGNOSTICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2009
Last Update Date: 12/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 MARKET ST
ST AUGUSTINE FL
32095-8891
US

IV. Provider business mailing address

650 MARKET ST
ST AUGUSTINE FL
32095-8891
US

V. Phone/Fax

Practice location:
  • Phone: 386-951-6654
  • Fax: 386-868-5010
Mailing address:
  • Phone: 386-951-6654
  • Fax: 386-868-5010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number4CC8494
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License NumberHCC8494
License Number StateFL

VIII. Authorized Official

Name: MR. ERNEST E HALE III
Title or Position: OWNER
Credential:
Phone: 386-951-6654