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General NPI Number Information
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NPI Number | 1114534385
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Entity Type | Organization
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Legal Business Name | NATURE COAST PRIMARY CARE LAB LLC
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Dates
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Enumeration Date | 09/30/2020
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Last Update Date | 11/05/2020
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Provider Practice Location Address
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Address Line | 7562 W GULF TO LAKE HWY
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City | CRYSTAL RIVER
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State | FL
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Zip | 34429-7840
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Country | US
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Telephone | 352-436-4328
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Fax | 352-260-0960
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Provider Business Mailing Address
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Address Line | 4918 SW 107TH LOOP
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City | OCALA
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State | FL
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Zip | 34476-4723
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Country | US
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Telephone | 352-362-0627
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Fax | 877-573-9013
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Authorized Official
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Title or Position | DELEGATED OFFICIAL
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Name | MR. EDWARD R KOP
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Credential |
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Telephone | 352-362-0627
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number |
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License Number State |
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