=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053920157
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAB TEST 4 U
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2020
-----------------------------------------------------
Last Update Date | 07/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 403 SW 103RD AVE APT 301
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33025-1881
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-662-8603
-----------------------------------------------------
Fax | 754-704-9003
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 260124
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33026-7124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-662-8603
-----------------------------------------------------
Fax | 754-704-9003
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MAUREEN VICTORIA SMITH
-----------------------------------------------------
Credential | CT SPECIMENCOLLECTOR
-----------------------------------------------------
Telephone | 954-662-8603
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZC0008X
-----------------------------------------------------
Taxonomy Name | Clinical Informatics (Pathology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------