=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346873338
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIAGNOSTIC LABS OF AMERICA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2020
-----------------------------------------------------
Last Update Date | 06/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3223 NW 10TH TER STE 606
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33309-5940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-570-2203
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 22305
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33335-2305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING
-----------------------------------------------------
Name | MISS SHANNON KOLLINGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-570-2203
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------