MEDICARE: ODET DIAGNOSTIC LABORATORY 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	:	1386214369
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ODET DIAGNOSTIC LABORATORY LLC

Provider Business Mailing Address
First Line	:	5906 FORUM SQ
Second Line	:
City	:	FREDERICK
State	:	MD
Zip	:	21703-2890
Country	:	US
Telephone Number	:	919-924-2240
Fax Number	:

Provider Business Practice Location Address
First Line	:	5906 FORUM SQ
Second Line	:
City	:	FREDERICK
State	:	MD
Zip	:	21703-2890
Country	:	US
Telephone Number	:	919-924-2240
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BRIDGET ODETUYI
Credential	:	LPN
Telephone Number	:	919-924-2240

Provider Enumeration Date	:	06/30/2021
Last Update Date	:	06/30/2021

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