Provider Demographics
NPI:1013930429
Name:FLORIDA FAMILY LABORATORY, INC.
Entity type:Organization
Organization Name:FLORIDA FAMILY LABORATORY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSHEYEV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-563-3309
Mailing Address - Street 1:7290 SW 42ND ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-4506
Mailing Address - Country:US
Mailing Address - Phone:800-563-3309
Mailing Address - Fax:800-833-1066
Practice Address - Street 1:7290 SW 42ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155
Practice Address - Country:US
Practice Address - Phone:800-563-3309
Practice Address - Fax:800-833-1066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL800001649291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL03007050Medicaid
FL03007050Medicaid