Healthcare Provider Details

I. General information

NPI: 1851554455
Provider Name (Legal Business Name): I MD PATHLAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 02/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N DIXIE HIGHWAY SUITE 308
WEST PALM BEACH FL
33401-2717
US

IV. Provider business mailing address

1500 N DIXIE HIGHWAY SUITE 308
WEST PALM BEACH FL
33401-2717
US

V. Phone/Fax

Practice location:
  • Phone: 561-236-1711
  • Fax: 561-736-9807
Mailing address:
  • Phone: 561-236-1711
  • Fax: 561-736-9807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License NumberME0069744
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: DR. CR JEANETTE MORALES-DUCRET
Title or Position: OWNER
Credential: MD
Phone: 561-236-1711