=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649676743
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIVING TREE LABORATORIES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2014
-----------------------------------------------------
Last Update Date | 11/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 555 HERITAGE DR STE 125
-----------------------------------------------------
City | JUPITER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33458-5287
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-408-6700
-----------------------------------------------------
Fax | 561-828-8531
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 555 HERITAGE DR STE 125
-----------------------------------------------------
City | JUPITER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33458-5287
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-499-5619
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MOSHE DUNOFF
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-499-5619
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 800027399
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------