Provider Demographics
NPI:1689139495
Name:MAINSTREAM DIAGNOSTIC LABORATORY LLC
Entity Type:Organization
Organization Name:MAINSTREAM DIAGNOSTIC LABORATORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAINELLYS
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLACIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-718-4002
Mailing Address - Street 1:5354 GULF DR
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-3920
Mailing Address - Country:US
Mailing Address - Phone:727-203-8391
Mailing Address - Fax:
Practice Address - Street 1:5354 GULF DR
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-3920
Practice Address - Country:US
Practice Address - Phone:727-203-8391
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-06
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory