Provider Demographics
NPI:1457863391
Name:PGN LAB LLC
Entity Type:Organization
Organization Name:PGN LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CORY
Authorized Official - Middle Name:BRANDON
Authorized Official - Last Name:HANLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-818-8054
Mailing Address - Street 1:4365 HICKORY DR
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-3905
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7847 SW ELLIPSE WAY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-7247
Practice Address - Country:US
Practice Address - Phone:561-818-8054
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-01
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory