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General NPI Number Information
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NPI Number | 1629604046
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Entity Type | Organization
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Legal Business Name | ANCIENT CITY DIAGNOSTICS, LLC
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Dates
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Enumeration Date | 03/17/2020
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Last Update Date | 03/17/2020
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Provider Practice Location Address
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Address Line | 150 SOUTHPARK BLVD STE 206
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City | SAINT AUGUSTINE
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State | FL
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Zip | 32086-5179
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Country | US
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Telephone | 904-439-3414
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Fax |
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Provider Business Mailing Address
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Address Line | 8563 ARGYLE BUSINESS LOOP STE 5
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City | JACKSONVILLE
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State | FL
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Zip | 32244-6613
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Country | US
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Telephone | 904-439-3414
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CHRISTOPHER EDMONDSON
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Credential |
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Telephone | 904-439-3414
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291900000X
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Taxonomy Name | Military Clinical Medical Laboratory
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License Number |
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License Number State |
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