Provider Demographics
NPI:1518392653
Name:HISTOPATH LAB, PA- GENOMICS
Entity Type:Organization
Organization Name:HISTOPATH LAB, PA- GENOMICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:WARE
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-527-1344
Mailing Address - Street 1:2671 W NORVELL BRYANT HWY
Mailing Address - Street 2:
Mailing Address - City:LECANTO
Mailing Address - State:FL
Mailing Address - Zip Code:34461-9440
Mailing Address - Country:US
Mailing Address - Phone:352-527-1344
Mailing Address - Fax:352-527-2259
Practice Address - Street 1:2671 W NORVELL BRYANT HWY
Practice Address - Street 2:
Practice Address - City:LECANTO
Practice Address - State:FL
Practice Address - Zip Code:34461-9440
Practice Address - Country:US
Practice Address - Phone:352-527-1344
Practice Address - Fax:352-527-2259
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HISTOPATH LAB, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-09-09
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL800001816291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009504100Medicaid
FL1518392653OtherNPI
FL1518392653OtherNPI