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General NPI Number Information
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NPI Number | 1376912642
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Entity Type | Organization
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Legal Business Name | ORANGE GROVE LABS LLC
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Dates
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Enumeration Date | 09/17/2015
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Last Update Date | 12/29/2016
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Provider Practice Location Address
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Address Line | 1325 S KILLIAN DR UNIT 3A
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City | LAKE PARK
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State | FL
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Zip | 33403-1965
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Country | US
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Telephone | 561-567-0063
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Fax | 561-847-4466
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Provider Business Mailing Address
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Address Line | 1325 S KILLIAN DR UNIT 3A
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City | LAKE PARK
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State | FL
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Zip | 33403-1965
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Country | US
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Telephone | 561-567-0063
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | MR. LOUIS DEVALEIX
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Credential |
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Telephone | 561-567-0063
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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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