MEDICARE: DIAGNOSTIC LABS OF AMERICA 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	:	1346873338
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIAGNOSTIC LABS OF AMERICA LLC

Provider Business Mailing Address
First Line	:	PO BOX 22305
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33335-2305
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3223 NW 10TH TER STE 606
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33309-5940
Country	:	US
Telephone Number	:	561-570-2203
Fax Number	:

Authorized Official
Title or Position	:	BILLING
Name	:	MISS SHANNON KOLLINGER
Credential	:
Telephone Number	:	561-570-2203

Provider Enumeration Date	:	02/18/2020
Last Update Date	:	06/18/2020

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