MEDICARE: OAKRIDGE CLINICAL 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		FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	L9099	OTHER	FL	BC BS PROVIDER ID

General Provider Information

NPI Number	:	1306990668
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OAKRIDGE CLINICAL LAB LLC

Provider Business Mailing Address
First Line	:	1000 NE 56TH ST
Second Line	:	ATTN BUSINESS OFFICE
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33334-4149
Country	:	US
Telephone Number	:	954-958-0606
Fax Number	:	954-116-0821

Provider Business Practice Location Address
First Line	:	1000 NE 56TH ST
Second Line	:	ATTN BUSINESS OFFICE
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33334-4149
Country	:	US
Telephone Number	:	954-958-0606
Fax Number	:	954-116-0821

Authorized Official
Title or Position	:	MANAGER BUSINESS OFFICE
Name	:	MR. FRITZ PHANORD
Credential	:
Telephone Number	:	95495870606

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	08/22/2020

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