Healthcare Provider Details

I. General information

NPI: 1356657787
Provider Name (Legal Business Name): SOVEREIGN LABORATORY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2010
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 KINDERKAMACK RD STE 101B
ORADELL NJ
07649-1600
US

IV. Provider business mailing address

680 KINDERKAMACK RD SUITE 300 3RD FLOOR
ORADELL NJ
07649-1600
US

V. Phone/Fax

Practice location:
  • Phone: 201-994-4069
  • Fax:
Mailing address:
  • Phone: 201-994-4069
  • Fax: 201-301-8892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateNJ

VIII. Authorized Official

Name: DR. JOHN H. HAJJAR
Title or Position: MD
Credential:
Phone: 201-994-4069