Provider Demographics
NPI:1679829204
Name:SOUTH FLORIDA LABORATORY, LLC
Entity Type:Organization
Organization Name:SOUTH FLORIDA LABORATORY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-889-0335
Mailing Address - Street 1:PO BOX 904107
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28290-4107
Mailing Address - Country:US
Mailing Address - Phone:954-889-0335
Mailing Address - Fax:305-554-4828
Practice Address - Street 1:3395 LAKEWORTH RD
Practice Address - Street 2:SUITE 1
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33463
Practice Address - Country:US
Practice Address - Phone:954-889-0335
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-01
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL800026470291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory