Provider Demographics
NPI:1376809426
Name:HGA LAB LLC
Entity Type:Organization
Organization Name:HGA LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGRM
Authorized Official - Prefix:
Authorized Official - First Name:RAMAKRISHNA
Authorized Official - Middle Name:P
Authorized Official - Last Name:KANURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-597-1206
Mailing Address - Street 1:12190 CORTEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-5578
Mailing Address - Country:US
Mailing Address - Phone:352-597-1206
Mailing Address - Fax:352-597-9715
Practice Address - Street 1:12190 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-5578
Practice Address - Country:US
Practice Address - Phone:352-597-1206
Practice Address - Fax:352-597-9715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8000015297291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory