Provider Demographics
NPI:1184403685
Name:MEDILAB INC
Entity type:Organization
Organization Name:MEDILAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MESA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-588-0106
Mailing Address - Street 1:1860 SE PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-5545
Mailing Address - Country:US
Mailing Address - Phone:305-588-0106
Mailing Address - Fax:
Practice Address - Street 1:1860 SE PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5545
Practice Address - Country:US
Practice Address - Phone:305-588-0106
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-25
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physicianGroup - Single Specialty