Provider Demographics
NPI:1760651681
Name:SAGE MEDICAL LABORATORY, LLC
Entity Type:Organization
Organization Name:SAGE MEDICAL LABORATORY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:S
Authorized Official - Last Name:DANTINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-676-0820
Mailing Address - Street 1:PO BOX 10540
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32120-0540
Mailing Address - Country:US
Mailing Address - Phone:386-944-0826
Mailing Address - Fax:386-677-6783
Practice Address - Street 1:533 N NOVA RD
Practice Address - Street 2:SUITE 202
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-4447
Practice Address - Country:US
Practice Address - Phone:386-944-0826
Practice Address - Fax:386-677-6783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory