Provider Demographics
NPI:1366836066
Name:FST LAB, LLC
Entity Type:Organization
Organization Name:FST LAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRITZ
Authorized Official - Middle Name:
Authorized Official - Last Name:MAIGNAN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:203-870-6050
Mailing Address - Street 1:48 ALPINE ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06610-1727
Mailing Address - Country:US
Mailing Address - Phone:203-870-6050
Mailing Address - Fax:203-333-9098
Practice Address - Street 1:48 ALPINE ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-1727
Practice Address - Country:US
Practice Address - Phone:203-870-6050
Practice Address - Fax:203-333-9098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-20
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT07D2023800291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory