MEDICARE: PATRIOT 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	:	1619718087
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATRIOT LABORATORY LLC

Provider Business Mailing Address
First Line	:	3705 S HWY 27
Second Line	:
City	:	CLERMONT
State	:	FL
Zip	:	34711-7950
Country	:	US
Telephone Number	:	407-446-6556
Fax Number	:	888-304-2622

Provider Business Practice Location Address
First Line	:	2380 SUNSET POINT RD
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33765-1430
Country	:	US
Telephone Number	:	727-466-1028
Fax Number	:	727-232-9779

Authorized Official
Title or Position	:	COO
Name	:	VICKI REGINA
Credential	:
Telephone Number	:	407-446-6556

Provider Enumeration Date	:	06/01/2024
Last Update Date	:	11/20/2025

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