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General NPI Number Information
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NPI Number | 1912634874
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Entity Type | Organization
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Legal Business Name | LAB SOURCE ONE LLC
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Dates
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Enumeration Date | 08/02/2022
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Last Update Date | 09/27/2022
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Provider Practice Location Address
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Address Line | 132 32ND ST STE 210
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City | BROOKLYN
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State | NY
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Zip | 11232-1833
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Country | US
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Telephone | 929-539-6804
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Fax |
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Provider Business Mailing Address
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Address Line | 132 32ND ST STE 210
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City | BROOKLYN
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State | NY
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Zip | 11232-1833
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Country | US
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Telephone | 929-539-6804
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Fax |
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Authorized Official
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Title or Position | LAB DIRECTOR
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Name | MR. STANISLAV GRINBERG
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Credential | PHD
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Telephone | 929-539-6804
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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 |
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License Number State |
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