Provider Demographics
NPI:1760192546
Name:PRESTIGE CLINICIANS -LABORATORY LLC
Entity Type:Organization
Organization Name:PRESTIGE CLINICIANS -LABORATORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ODAZIE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:954-496-2599
Mailing Address - Street 1:331 NW 27TH AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33311-8632
Mailing Address - Country:US
Mailing Address - Phone:954-496-2599
Mailing Address - Fax:
Practice Address - Street 1:331 NW 27TH AVE STE 1
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33311-8632
Practice Address - Country:US
Practice Address - Phone:954-496-2599
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory