Provider Demographics
NPI:1043935950
Name:AMERICAN MEDICAL LABORATORY LLC
Entity Type:Organization
Organization Name:AMERICAN MEDICAL LABORATORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-696-6157
Mailing Address - Street 1:14221-A WILLARD ROAD SUITE 200
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151
Mailing Address - Country:US
Mailing Address - Phone:949-696-6157
Mailing Address - Fax:
Practice Address - Street 1:4221 WALNEY RD STE 401B
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-2987
Practice Address - Country:US
Practice Address - Phone:949-696-6157
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-04
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory