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General NPI Number Information
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NPI Number | 1457863391
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Entity Type | Organization
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Legal Business Name | PGN LAB LLC
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Dates
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Enumeration Date | 11/01/2017
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Last Update Date | 11/01/2017
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Provider Practice Location Address
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Address Line | 7847 SW ELLIPSE WAY
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City | STUART
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State | FL
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Zip | 34997-7247
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Country | US
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Telephone | 561-818-8054
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Fax |
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Provider Business Mailing Address
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Address Line | 4365 HICKORY DR
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City | PALM BEACH GARDENS
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State | FL
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Zip | 33418-3905
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. CORY BRANDON HANLON
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Credential |
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Telephone | 561-818-8054
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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 | FL
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