MEDICARE: AZMED 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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1104465954
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AZMED LAB LLC

Provider Business Mailing Address
First Line	:	2950 S ALMA SCHOOL RD STE 14
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85210-4036
Country	:	US
Telephone Number	:	602-492-8512
Fax Number	:

Provider Business Practice Location Address
First Line	:	2950 S ALMA SCHOOL RD STE 14
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85210-4036
Country	:	US
Telephone Number	:	602-492-8512
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JOSH ADAMS
Credential	:
Telephone Number	:	502-415-2836

Provider Enumeration Date	:	12/26/2019
Last Update Date	:	12/26/2019

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