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General NPI Number Information
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NPI Number | 1689139495
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Entity Type | Organization
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Legal Business Name | MAINSTREAM DIAGNOSTIC LABORATORY LLC
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Dates
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Enumeration Date | 02/06/2019
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Last Update Date | 01/27/2020
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Provider Practice Location Address
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Address Line | 5354 GULF DR
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City | NEW PORT RICHEY
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State | FL
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Zip | 34652-3920
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Country | US
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Telephone | 727-203-8391
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Fax |
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Provider Business Mailing Address
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Address Line | 5354 GULF DR
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City | NEW PORT RICHEY
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State | FL
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Zip | 34652-3920
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Country | US
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Telephone | 727-203-8391
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DAINELLYS VILLACIS
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Credential |
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Telephone | 786-718-4002
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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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