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General NPI Number Information
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NPI Number | 1588163505
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Entity Type | Organization
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Legal Business Name | CLG DIAGNOSTICS. LLC
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Dates
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Enumeration Date | 02/05/2018
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Last Update Date | 03/17/2018
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Provider Practice Location Address
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Address Line | 11350 SW VILLAGE PKWY STE 307
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34987-2352
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Country | US
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Telephone | 603-328-8633
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1254
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City | SALEM
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State | NH
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Zip | 03079-1138
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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 | DIRECTOR OF COMPLIANCE
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Name | MRS. LISA PERRY
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Credential |
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Telephone | 603-328-8633
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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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