Provider Demographics
NPI:1043245038
Name:FLORIDA DEPARTMENT OF HEALTH
Entity Type:Organization
Organization Name:FLORIDA DEPARTMENT OF HEALTH
Other - Org Name:DOH BUREAU OF LABORATORIES - LANTANA
Other - Org Type:Other Name
Authorized Official - Title/Position:LANTANA LAB DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-540-1170
Mailing Address - Street 1:1199 LANTANA RD BLDG 31
Mailing Address - Street 2:
Mailing Address - City:LANTANA
Mailing Address - State:FL
Mailing Address - Zip Code:33462-1514
Mailing Address - Country:US
Mailing Address - Phone:561-540-1170
Mailing Address - Fax:
Practice Address - Street 1:1217 N PEARL ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32202-3926
Practice Address - Country:US
Practice Address - Phone:904-791-1690
Practice Address - Fax:904-791-1626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL800000290291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL030737800Medicaid
FLL8322OtherBC/BS
FLL8322OtherBC/BS