Healthcare Provider Details

I. General information

NPI: 1003963273
Provider Name (Legal Business Name): AMERICAN DIAGNSOTIC LAB., INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 MAIN ST
BROCKTON MA
02301-4046
US

IV. Provider business mailing address

144 MAIN ST
BROCKTON MA
02301-4046
US

V. Phone/Fax

Practice location:
  • Phone: 508-984-5200
  • Fax: 508-996-8614
Mailing address:
  • Phone: 508-984-5200
  • Fax: 508-996-8614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number34550
License Number StateMA

VIII. Authorized Official

Name: MRS. ELIZABETH C MEDEIROS
Title or Position: MANAGER
Credential:
Phone: 508-984-5200