MEDICARE: INDEPENDENT CLINICAL LABORATORIES 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	800001312	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285707943
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENT CLINICAL LABORATORIES LLC

Provider Business Mailing Address
First Line	:	22 WESTEDGE ST STE 800
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29403-6984
Country	:	US
Telephone Number	:	854-429-1069
Fax Number	:	833-247-4091

Provider Business Practice Location Address
First Line	:	3110 CHERRY PALM DR
Second Line	:	SUITE 340
City	:	TAMPA
State	:	FL
Zip	:	33619-8304
Country	:	US
Telephone Number	:	813-932-0374
Fax Number	:	813-931-0658

Authorized Official
Title or Position	:	COO
Name	:	DANIEL NODES
Credential	:
Telephone Number	:	843-754-7748

Provider Enumeration Date	:	11/17/2006
Last Update Date	:	06/04/2025

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