=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508133372
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LODDSTONE LAB GROUP OF FLORIDA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2011
-----------------------------------------------------
Last Update Date | 07/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 409 W HALLANDALE BEACH BLVD # 208
-----------------------------------------------------
City | HALLANDALE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33009-5301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-236-3879
-----------------------------------------------------
Fax | 954-457-8111
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 409 W HALLANDALE BEACH BLVD # 208
-----------------------------------------------------
City | HALLANDALE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33009-5301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-236-3879
-----------------------------------------------------
Fax | 954-457-8111
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANTOINETA LOUREIRO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-236-3879
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 800026240
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------