MEDICARE: SOUTH FLORIDA 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	800026470	FL

General Provider Information

NPI Number	:	1679829204
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH FLORIDA LABORATORY, LLC

Provider Business Mailing Address
First Line	:	PO BOX 904107
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28290-4107
Country	:	US
Telephone Number	:	954-889-0335
Fax Number	:	305-554-4828

Provider Business Practice Location Address
First Line	:	3395 LAKEWORTH RD
Second Line	:	SUITE 1
City	:	LAKE WORTH
State	:	FL
Zip	:	33463
Country	:	US
Telephone Number	:	954-889-0335
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MARC TANNER
Credential	:
Telephone Number	:	954-889-0335

Provider Enumeration Date	:	08/01/2012
Last Update Date	:	08/01/2012

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