Provider Demographics
NPI:1619073442
Name:MILLENIUM LABORATORIES LLC
Entity Type:Organization
Organization Name:MILLENIUM LABORATORIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGRM
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:F
Authorized Official - Last Name:EGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-926-3063
Mailing Address - Street 1:PO BOX 281117
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-1117
Mailing Address - Country:US
Mailing Address - Phone:813-396-9975
Mailing Address - Fax:813-396-9977
Practice Address - Street 1:3602 SPECTRUM BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9401
Practice Address - Country:US
Practice Address - Phone:813-396-9975
Practice Address - Fax:813-396-9977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL800020748291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLL9296OtherBCBS PROVIDER NUMBER
FL=========00OtherOHIO BUREAU OF WORKER'S C
FLL9296OtherBCBS PROVIDER NUMBER