Provider Demographics
NPI:1225424294
Name:ATLANTIC DIAGNOSTIC LABORATORIES, LLC
Entity Type:Organization
Organization Name:ATLANTIC DIAGNOSTIC LABORATORIES, LLC
Other - Org Name:INNOVATIVE LABORATORY SERVICES INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:AARON
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMENICO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-525-2470
Mailing Address - Street 1:3520 PROGRESS DR STE C
Mailing Address - Street 2:
Mailing Address - City:BENSALEM
Mailing Address - State:PA
Mailing Address - Zip Code:19020-5810
Mailing Address - Country:US
Mailing Address - Phone:866-465-6763
Mailing Address - Fax:
Practice Address - Street 1:8419 SHARON MERCER RD
Practice Address - Street 2:
Practice Address - City:MERCER
Practice Address - State:PA
Practice Address - Zip Code:16137-3169
Practice Address - Country:US
Practice Address - Phone:724-685-1376
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-07
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA39D2069737291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1030010040001Medicaid