Provider Demographics
NPI:1073385233
Name:WATER GLASS LABORATORIES TAMPA BAY LLC
Entity Type:Organization
Organization Name:WATER GLASS LABORATORIES TAMPA BAY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:RIVARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-677-1018
Mailing Address - Street 1:5880 49TH ST N STE 205
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33709-2147
Mailing Address - Country:US
Mailing Address - Phone:727-677-1018
Mailing Address - Fax:
Practice Address - Street 1:5880 49TH ST N STE 205
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-2147
Practice Address - Country:US
Practice Address - Phone:727-677-1018
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-23
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory