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General NPI Number Information
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NPI Number | 1821001330
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Entity Type | Organization
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Legal Business Name | ST JOHNS BIOMEDICAL LABORATORIES INC
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Dates
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Enumeration Date | 08/14/2006
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Last Update Date | 06/17/2008
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Provider Practice Location Address
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Address Line | 165 SOUTHPARK BLVD SUITE A
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City | ST AUGUSTINE
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State | FL
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Zip | 32086-4101
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Country | US
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Telephone | 904-824-5497
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Fax | 904-824-8257
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Provider Business Mailing Address
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Address Line | PO BOX 860206 165 SOUTHPARK BLVD
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City | ST. AUGUSTINE
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State | FL
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Zip | 32086-0206
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Country | US
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Telephone | 904-824-5497
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Fax | 904-824-8257
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Authorized Official
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Title or Position | DIRECTOR/OWNER
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Name | EDWIN OLIVA SIA
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Credential | MD, BCLD(ABB)
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Telephone | 904-824-5497
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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 | 800001722
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License Number State | FL
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