Provider Demographics
NPI:1013083468
Name:WEST BROWARD CLINICAL LABORATORY, L.L.C.
Entity Type:Organization
Organization Name:WEST BROWARD CLINICAL LABORATORY, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:DAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-739-0978
Mailing Address - Street 1:4850 W OAKLAND PARK BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33313-7260
Mailing Address - Country:US
Mailing Address - Phone:954-739-3030
Mailing Address - Fax:954-739-6010
Practice Address - Street 1:4850 W OAKLAND PARK BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33313-7260
Practice Address - Country:US
Practice Address - Phone:954-739-3030
Practice Address - Fax:954-739-6010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
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
FLE9191Medicare ID - Type Unspecified