Provider Demographics
NPI:1477325108
Name:BLUE ANGEL DIAGNOSTIC LAB LLC
Entity Type:Organization
Organization Name:BLUE ANGEL DIAGNOSTIC LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:EDMOND-VOLMAR
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, ARNP, FNP-BC
Authorized Official - Phone:954-778-4344
Mailing Address - Street 1:6662 SCHOONER TER
Mailing Address - Street 2:
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063-8326
Mailing Address - Country:US
Mailing Address - Phone:954-778-4344
Mailing Address - Fax:
Practice Address - Street 1:2300 W SAMPLE RD STE 212
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33073-3048
Practice Address - Country:US
Practice Address - Phone:954-778-4344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory