MEDICARE: SAGE MEDICAL 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		FL

General Provider Information

NPI Number	:	1760651681
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAGE MEDICAL LABORATORY, LLC

Provider Business Mailing Address
First Line	:	PO BOX 10540
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32120-0540
Country	:	US
Telephone Number	:	386-944-0826
Fax Number	:	386-677-6783

Provider Business Practice Location Address
First Line	:	533 N NOVA RD
Second Line	:	SUITE 202
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-4447
Country	:	US
Telephone Number	:	386-944-0826
Fax Number	:	386-677-6783

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CHRIS S DANTINI
Credential	:
Telephone Number	:	386-676-0820

Provider Enumeration Date	:	02/25/2008
Last Update Date	:	12/19/2008

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