=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841656675
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SCIENTIFIC LABORATORY COMPANY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2016
-----------------------------------------------------
Last Update Date | 05/31/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3395 LAKE WORTH RD STE 1
-----------------------------------------------------
City | PALM SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33461-6902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-855-2469
-----------------------------------------------------
Fax | 561-855-2479
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3395 LAKE WORTH RD STE 1
-----------------------------------------------------
City | PALM SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33461-6902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-855-2469
-----------------------------------------------------
Fax | 561-855-2479
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | CARLOS HERNANDEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-290-4773
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------