=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346557022
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROVIDENCE CLINICAL LAB, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2010
-----------------------------------------------------
Last Update Date | 09/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 317 AVA AVE
-----------------------------------------------------
City | SOMERDALE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08083-1603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-534-5367
-----------------------------------------------------
Fax | 856-435-6067
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 213
-----------------------------------------------------
City | SOMERDALE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08083-0213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-534-5367
-----------------------------------------------------
Fax | 856-435-6067
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MS. CAROL JOAN EVANS
-----------------------------------------------------
Credential | B.O.R ASCP CERTIFIED
-----------------------------------------------------
Telephone | 856-534-5367
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 1492292
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 1492292
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------