MEDICARE: REAL LIFE LAB, 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	:	1720419658
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REAL LIFE LAB, LLC

Provider Business Mailing Address
First Line	:	258 SE 6TH AVE
Second Line	:	SUITE 8
City	:	DELRAY BEACH
State	:	FL
Zip	:	33483-5259
Country	:	US
Telephone Number	:	561-265-5951
Fax Number	:

Provider Business Practice Location Address
First Line	:	258 SE 6TH AVE
Second Line	:	SUITE 8
City	:	DELRAY BEACH
State	:	FL
Zip	:	33483-5259
Country	:	US
Telephone Number	:	561-265-5951
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	ERIC SNYDER
Credential	:
Telephone Number	:	561-265-5951

Provider Enumeration Date	:	12/03/2013
Last Update Date	:	12/03/2013

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