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General NPI Number Information
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NPI Number | 1902343536
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Entity Type | Organization
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Legal Business Name | PHYSICIANS STAT LAB EAST COAST, LLC
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Dates
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Enumeration Date | 01/20/2017
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Last Update Date | 10/29/2018
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Provider Practice Location Address
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Address Line | 1355 37TH ST STE 401
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City | VERO BEACH
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State | FL
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Zip | 32960-7322
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Country | US
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Telephone | 772-569-6000
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Fax |
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Provider Business Mailing Address
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Address Line | 777 37TH ST A107
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City | VERO BEACH
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State | FL
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Zip | 32960
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Country | US
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Telephone | 772-569-6000
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. NATHAN HAWKINS
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Credential |
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Telephone | 407-757-8747
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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 | 31702004
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License Number State | FL
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