Provider Demographics
NPI:1740677467
Name:FLO-MEDILAB SERVICES, LLC
Entity type:Organization
Organization Name:FLO-MEDILAB SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAQUELYN
Authorized Official - Middle Name:ALICE
Authorized Official - Last Name:AGASAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:407-369-8125
Mailing Address - Street 1:716 HUGHEY ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-5626
Mailing Address - Country:US
Mailing Address - Phone:844-356-6334
Mailing Address - Fax:512-532-0923
Practice Address - Street 1:716 HUGHEY ST UNIT B
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-5626
Practice Address - Country:US
Practice Address - Phone:844-356-6334
Practice Address - Fax:512-532-0923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-21
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
10D2093547291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10D2093547OtherCLIA