Provider Demographics
NPI:1235208992
Name:ACE CLINICAL LABORATORY, INC
Entity Type:Organization
Organization Name:ACE CLINICAL LABORATORY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:WILLOWMENIA
Authorized Official - Middle Name:ISDORA
Authorized Official - Last Name:COSTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-462-4400
Mailing Address - Street 1:283 COMMACK ROAD
Mailing Address - Street 2:SUITE 315
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725
Mailing Address - Country:US
Mailing Address - Phone:631-462-4400
Mailing Address - Fax:631-462-3431
Practice Address - Street 1:283 COMMACK ROAD
Practice Address - Street 2:SUITE 204
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725
Practice Address - Country:US
Practice Address - Phone:631-462-4400
Practice Address - Fax:631-462-3431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPFI4386291U00000X
NYCLIA33D0674863291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01350994Medicaid
NY01350994Medicaid