MEDICARE: PMDLAB, 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	CLF 11680	CA

General Provider Information

NPI Number	:	1841724895
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PMDLAB, LLC

Provider Business Mailing Address
First Line	:	3440 N 16TH ST STE 200
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-7125
Country	:	US
Telephone Number	:	781-626-1212
Fax Number	:

Provider Business Practice Location Address
First Line	:	4630 NORTHGATE BLVD STE 150
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95834-1141
Country	:	US
Telephone Number	:	916-776-8240
Fax Number	:	916-597-1379

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	PETER SIMMONS
Credential	:
Telephone Number	:	781-626-1212

Provider Enumeration Date	:	04/17/2017
Last Update Date	:	05/06/2021

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