=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770980062
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMART LAB LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2014
-----------------------------------------------------
Last Update Date | 06/30/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10385 IRONWOOD RD SUITE 130
-----------------------------------------------------
City | PALM BEACH GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33410-4291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-513-8440
-----------------------------------------------------
Fax | 561-370-6036
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10385 IRONWOOD RD SUITE 130
-----------------------------------------------------
City | PALM BEACH GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33410-4291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-513-8440
-----------------------------------------------------
Fax | 561-370-6036
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATING OFFICER
-----------------------------------------------------
Name | MR. JUSTIN MORGAN WAYNE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-513-8440
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------