MEDICARE: SRCONQUEST

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	C5Q7D6S2	FL

General Provider Information

NPI Number	:	1508241936
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SRCONQUEST

Provider Business Mailing Address
First Line	:	3255 NW 94TH AVE
Second Line	:	#8736
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33075-2001
Country	:	US
Telephone Number	:	954-805-4480
Fax Number	:	954-805-4480

Provider Business Practice Location Address
First Line	:	3255 NW 94TH AVE
Second Line	:	#8736
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33075-2001
Country	:	US
Telephone Number	:	954-805-4480
Fax Number	:	954-805-4480

Authorized Official
Title or Position	:	CEO
Name	:	MR. DWAYNE COOMBS
Credential	:
Telephone Number	:	954-805-4480

Provider Enumeration Date	:	07/27/2015
Last Update Date	:	07/27/2015

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Directions to “SRCONQUEST ” Practice Location

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