Healthcare Provider Details

I. General information

NPI: 1629047436
Provider Name (Legal Business Name): BROOKSIDE CLINICAL LABORATORY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 11/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 DUTTON MILL RD STE 100
ASTON PA
19014-2850
US

IV. Provider business mailing address

2901 DUTTON MILL RD STE 100
ASTON PA
19014-2850
US

V. Phone/Fax

Practice location:
  • Phone: 610-872-6466
  • Fax: 610-872-7628
Mailing address:
  • Phone: 610-872-6466
  • Fax: 610-872-7628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberPA000472
License Number StatePA

VIII. Authorized Official

Name: MR. JOHN J IACONO
Title or Position: OWNER DIRECTOR
Credential: BS
Phone: 610-872-6466