Provider Demographics
NPI:1033281324
Name:ADVANCED CLINICAL LABORATORIES, INC.
Entity Type:Organization
Organization Name:ADVANCED CLINICAL LABORATORIES, INC.
Other - Org Name:VISTA CLINICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EX DIRECTOR OF ADMINISTRATION
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:OWEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-536-9270
Mailing Address - Street 1:3705 S HWY 27 STE 101
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-7950
Mailing Address - Country:US
Mailing Address - Phone:352-536-9270
Mailing Address - Fax:352-536-9279
Practice Address - Street 1:3705 S HWY 27 STE 101
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-7950
Practice Address - Country:US
Practice Address - Phone:352-536-9270
Practice Address - Fax:352-536-9279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL800018668291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL030774200Medicaid
FLE9131Medicare ID - Type Unspecified