=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184620775
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIAGNOSTIC LABORATORY MEDICINE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2005
-----------------------------------------------------
Last Update Date | 07/12/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14 CROSBY DR
-----------------------------------------------------
City | BEDFORD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01730-1451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-582-6248
-----------------------------------------------------
Fax | 781-275-9689
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14 CROSBY DRIVE
-----------------------------------------------------
City | BEDFORD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01730-1451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-582-6248
-----------------------------------------------------
Fax | 781-275-9689
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LABORATORY DIRECTOR
-----------------------------------------------------
Name | DR. JOSEPH MUSTO
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 800-582-6248
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 2373
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------