Provider Demographics
NPI:1770980062
Name:SMART LAB LLC
Entity type:Organization
Organization Name:SMART LAB LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:MORGAN
Authorized Official - Last Name:WAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-513-8440
Mailing Address - Street 1:10385 IRONWOOD RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-4291
Mailing Address - Country:US
Mailing Address - Phone:561-513-8440
Mailing Address - Fax:561-370-6036
Practice Address - Street 1:10385 IRONWOOD RD
Practice Address - Street 2:SUITE 130
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-4291
Practice Address - Country:US
Practice Address - Phone:561-513-8440
Practice Address - Fax:561-370-6036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-02
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACOS 00800603OtherSTATE LICENSE
WI100049019Medicaid
OH0155902Medicaid
FL800027631OtherSTATE LICENSE
UT1770980062Medicaid
PA34458OtherSTATE LICENSE
P01611847OtherRR MEDICARE
VT1025400Medicaid
FL015049900Medicaid
IH908AOtherMEDICARE PTAN