Provider Demographics
NPI:1770591489
Name:GRANITE DIAGNOSTIC LABORATORIES, INC.
Entity type:Organization
Organization Name:GRANITE DIAGNOSTIC LABORATORIES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:GRANITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-771-6343
Mailing Address - Street 1:2150 ALT 19
Mailing Address - Street 2:SUITE A
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-5363
Mailing Address - Country:US
Mailing Address - Phone:727-771-6343
Mailing Address - Fax:727-771-2942
Practice Address - Street 1:2150 ALT 19
Practice Address - Street 2:SUITE A
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-5363
Practice Address - Country:US
Practice Address - Phone:727-771-6343
Practice Address - Fax:727-771-2942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL800009395291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL030705000Medicaid
FL030705000Medicaid