=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730840653
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MORCELLA LABS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2022
-----------------------------------------------------
Last Update Date | 01/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9858 CLINT MOORE RD # C111126
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33496-1034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-515-1260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9858 CLINT MOORE RD # C111126
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33496-1034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-515-1260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | MARDOCHEE MONESTIME
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-328-4352
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------