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General NPI Number Information
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NPI Number | 1659694503
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Entity Type | Organization
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Legal Business Name | CLINICAL LABORATORY GROUP INC
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Dates
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Enumeration Date | 03/07/2010
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Last Update Date | 03/07/2010
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Provider Practice Location Address
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Address Line | 298 S LAWRENCE BLVD
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City | KEYSTONE HEIGHTS
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State | FL
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Zip | 32656-9217
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Country | US
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Telephone | 352-473-8483
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Fax |
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Provider Business Mailing Address
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Address Line | 19804 NE 22ND LN
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City | HAWTHORNE
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State | FL
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Zip | 32640-2900
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Country | US
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Telephone | 352-514-7920
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. DARREN DAVID LOTOW
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Credential |
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Telephone | 352-514-7920
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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 | 10D200128
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License Number State | FL
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