Provider Demographics
NPI:1114534385
Name:NATURE COAST PRIMARY CARE LAB LLC
Entity Type:Organization
Organization Name:NATURE COAST PRIMARY CARE LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DELEGATED OFFICIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:R
Authorized Official - Last Name:KOP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-362-0627
Mailing Address - Street 1:4918 SW 107TH LOOP
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34476-4723
Mailing Address - Country:US
Mailing Address - Phone:352-362-0627
Mailing Address - Fax:877-573-9013
Practice Address - Street 1:7562 W GULF TO LAKE HWY
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-7840
Practice Address - Country:US
Practice Address - Phone:352-436-4328
Practice Address - Fax:352-260-0960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-30
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory