Provider Demographics
NPI:1366674004
Name:THE LABORATORY GROUP OF NORTHWEST FLORIDA, PLLC
Entity Type:Organization
Organization Name:THE LABORATORY GROUP OF NORTHWEST FLORIDA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NORTH
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-438-1154
Mailing Address - Street 1:4724 N DAVIS HWY
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2339
Mailing Address - Country:US
Mailing Address - Phone:850-438-1154
Mailing Address - Fax:850-433-6034
Practice Address - Street 1:4724 N DAVIS HWY
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2339
Practice Address - Country:US
Practice Address - Phone:850-438-1154
Practice Address - Fax:850-433-6034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-13
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001697200Medicaid
FL001697200Medicaid