Provider Demographics
NPI:1477899649
Name:OCEAN STATE LAB LLC
Entity Type:Organization
Organization Name:OCEAN STATE LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:MR
Authorized Official - First Name:MOUSTAFA
Authorized Official - Middle Name:MOATAZ
Authorized Official - Last Name:ABOSHADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-305-7245
Mailing Address - Street 1:1525 OLD LOUISQUISSET PIKE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865-4503
Mailing Address - Country:US
Mailing Address - Phone:401-305-7245
Mailing Address - Fax:401-305-7698
Practice Address - Street 1:1525 OLD LOUISQUISSET PIKE
Practice Address - Street 2:SUITE 103
Practice Address - City:LINCOLN
Practice Address - State:RI
Practice Address - Zip Code:02865-4503
Practice Address - Country:US
Practice Address - Phone:401-305-7245
Practice Address - Fax:401-305-7698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-17
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory