Provider Demographics
NPI:1013353200
Name:MELBOURNE MEDICAL LABORATORY LLC
Entity type:Organization
Organization Name:MELBOURNE MEDICAL LABORATORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:DELIGDISH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-727-2990
Mailing Address - Street 1:95 BULLDOG BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3332
Mailing Address - Country:US
Mailing Address - Phone:321-727-2990
Mailing Address - Fax:321-724-0455
Practice Address - Street 1:95 BULLDOG BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3332
Practice Address - Country:US
Practice Address - Phone:321-722-1766
Practice Address - Fax:321-722-0346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-15
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory