Provider Demographics
NPI:1093494627
Name:EXCELSIOR DIAGNOSTICS LLC
Entity Type:Organization
Organization Name:EXCELSIOR DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WHITNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHYTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-799-6520
Mailing Address - Street 1:12724 GRAN BAY PKWY W STE 410
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-9486
Mailing Address - Country:US
Mailing Address - Phone:904-799-6520
Mailing Address - Fax:904-799-6588
Practice Address - Street 1:12724 GRAN BAY PKWY W STE 410
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-9486
Practice Address - Country:US
Practice Address - Phone:904-799-6520
Practice Address - Fax:904-799-6588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No293D00000XLaboratoriesPhysiological Laboratory