=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831499391
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LONG HILL DIAGNOSTICS GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2010
-----------------------------------------------------
Last Update Date | 10/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1272 LONG HILL RD
-----------------------------------------------------
City | STIRLING
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07980-1010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-748-2889
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7240
-----------------------------------------------------
City | JUPITER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33468-7240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-748-2889
-----------------------------------------------------
Fax | 561-748-1523
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING COMPANY
-----------------------------------------------------
Name | KAREN BARLOW
-----------------------------------------------------
Credential | PRESIDENT
-----------------------------------------------------
Telephone | 561-748-2889
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------