Provider Demographics
NPI:1821001330
Name:ST JOHNS BIOMEDICAL LABORATORIES INC
Entity Type:Organization
Organization Name:ST JOHNS BIOMEDICAL LABORATORIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:OLIVA
Authorized Official - Last Name:SIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD, BCLD(ABB)
Authorized Official - Phone:904-824-5497
Mailing Address - Street 1:PO BOX 860206
Mailing Address - Street 2:165 SOUTHPARK BLVD
Mailing Address - City:ST. AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-0206
Mailing Address - Country:US
Mailing Address - Phone:904-824-5497
Mailing Address - Fax:904-824-8257
Practice Address - Street 1:165 SOUTHPARK BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-4101
Practice Address - Country:US
Practice Address - Phone:904-824-5497
Practice Address - Fax:904-824-8257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL800001722291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10D0645082OtherCLIA
FL800001722OtherCLINICAL LAB LICENSE
FL030142600Medicaid
FLL8540Medicare PIN