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General NPI Number Information
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NPI Number | 1629047436
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Entity Type | Organization
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Legal Business Name | BROOKSIDE CLINICAL LABORATORY INC
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Dates
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Enumeration Date | 03/15/2006
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Last Update Date | 11/06/2018
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Provider Practice Location Address
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Address Line | 2901 DUTTON MILL RD STE 100
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City | ASTON
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State | PA
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Zip | 19014-2850
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Country | US
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Telephone | 610-872-6466
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Fax | 610-872-7628
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Provider Business Mailing Address
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Address Line | 2901 DUTTON MILL RD STE 100
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City | ASTON
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State | PA
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Zip | 19014-2850
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Country | US
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Telephone | 610-872-6466
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Fax | 610-872-7628
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Authorized Official
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Title or Position | OWNER DIRECTOR
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Name | MR. JOHN J IACONO
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Credential | BS
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Telephone | 610-872-6466
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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 | PA000472
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License Number State | PA
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