Provider Demographics
NPI:1962002501
Name:IMPAK DIAGNOSTICS LABORATORY 'LLC'
Entity Type:Organization
Organization Name:IMPAK DIAGNOSTICS LABORATORY 'LLC'
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SHUBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PIERRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-482-5388
Mailing Address - Street 1:36 GOVERNORS CT
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-7161
Mailing Address - Country:US
Mailing Address - Phone:631-482-5388
Mailing Address - Fax:
Practice Address - Street 1:5885 MARGATE BLVD
Practice Address - Street 2:
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33063-2834
Practice Address - Country:US
Practice Address - Phone:631-482-5388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory