MEDICARE: AZ LAB, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	4476	AZ
2	208D00000X	General Practice Physician	4476	AZ
3	207KA0200X	Allergy Physician	4476	AZ

General Provider Information

NPI Number	:	1013376151
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AZ LAB, LLC

Provider Business Mailing Address
First Line	:	2210 S MILL AVE
Second Line	:	8
City	:	TEMPE
State	:	AZ
Zip	:	85282-2153
Country	:	US
Telephone Number	:	623-242-0346
Fax Number	:

Provider Business Practice Location Address
First Line	:	2210 S MILL AVE
Second Line	:	8
City	:	TEMPE
State	:	AZ
Zip	:	85282-2153
Country	:	US
Telephone Number	:	623-242-0346
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JONNA ELAINE DEMORE
Credential	:
Telephone Number	:	623-242-0346

Provider Enumeration Date	:	02/17/2016
Last Update Date	:	02/17/2016

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Directions to “AZ LAB, LLC ” Practice Location

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