Provider Demographics
NPI:1508241936
Name:SRCONQUEST
Entity Type:Organization
Organization Name:SRCONQUEST
Other - Org Name:CONQUEST LABORATORIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:COOMBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-805-4480
Mailing Address - Street 1:3255 NW 94TH AVE
Mailing Address - Street 2:#8736
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33075-2001
Mailing Address - Country:US
Mailing Address - Phone:954-805-4480
Mailing Address - Fax:954-805-4480
Practice Address - Street 1:3255 NW 94TH AVE
Practice Address - Street 2:#8736
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33075-2001
Practice Address - Country:US
Practice Address - Phone:954-805-4480
Practice Address - Fax:954-805-4480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLC5Q7D6S2291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL246RP1900XMedicare PIN