Provider Demographics
NPI:1700819794
Name:TOMOKA MEDICAL LAB, INC.
Entity Type:Organization
Organization Name:TOMOKA MEDICAL LAB, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL TECHNOLOGIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:SALEH
Authorized Official - Last Name:SABOUNJI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-677-8014
Mailing Address - Street 1:783 S NOVA RD
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-7332
Mailing Address - Country:US
Mailing Address - Phone:386-677-8014
Mailing Address - Fax:386-673-8401
Practice Address - Street 1:783 S NOVA RD
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-7332
Practice Address - Country:US
Practice Address - Phone:386-677-8014
Practice Address - Fax:386-673-8401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLL8541Medicare ID - Type Unspecified