Provider Demographics
NPI:1225432867
Name:PROGRESSIVE MEDICAL LAB, LLC
Entity Type:Organization
Organization Name:PROGRESSIVE MEDICAL LAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:MAYADA
Authorized Official - Middle Name:
Authorized Official - Last Name:AL HUSSAINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-795-4324
Mailing Address - Street 1:345 BEVILLE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119-2165
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1690 DUNLAWTON AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-8979
Practice Address - Country:US
Practice Address - Phone:386-271-2273
Practice Address - Fax:386-845-0221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-10
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL800027387291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory