=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164053435
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERGRATED CLINICAL LABORATORY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2020
-----------------------------------------------------
Last Update Date | 08/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1701 GREEN RD STE A5-1
-----------------------------------------------------
City | DEERFIELD BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33064-1074
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-200-2053
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1700 NW 65TH AVE # 13A
-----------------------------------------------------
City | PLANTATION
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33313-4575
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-200-2053
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. PHILY A GIORGIANNI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-200-2053
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------