Healthcare Provider Details

I. General information

NPI: 1285707943
Provider Name (Legal Business Name): INDEPENDENT CLINICAL LABORATORIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 06/04/2025
Certification Date: 06/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3110 CHERRY PALM DR SUITE 340
TAMPA FL
33619-8304
US

IV. Provider business mailing address

22 WESTEDGE ST STE 800
CHARLESTON SC
29403-6984
US

V. Phone/Fax

Practice location:
  • Phone: 813-932-0374
  • Fax: 813-931-0658
Mailing address:
  • Phone: 854-429-1069
  • Fax: 833-247-4091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number800001312
License Number StateFL

VIII. Authorized Official

Name: DANIEL NODES
Title or Position: COO
Credential:
Phone: 843-754-7748