Provider Demographics
NPI:1346557022
Name:PROVIDENCE CLINICAL LAB, LLC
Entity Type:Organization
Organization Name:PROVIDENCE CLINICAL LAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:JOAN
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:BOR ASCP CERTIFIED
Authorized Official - Phone:856-534-5367
Mailing Address - Street 1:PO BOX 213
Mailing Address - Street 2:
Mailing Address - City:SOMERDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:08083-0213
Mailing Address - Country:US
Mailing Address - Phone:856-534-5367
Mailing Address - Fax:856-435-6067
Practice Address - Street 1:317 AVA AVE
Practice Address - Street 2:
Practice Address - City:SOMERDALE
Practice Address - State:NJ
Practice Address - Zip Code:08083-1603
Practice Address - Country:US
Practice Address - Phone:856-534-5367
Practice Address - Fax:856-435-6067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-01
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1492292251E00000X, 291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No251E00000XAgenciesHome Health