Provider Demographics
NPI:1811439433
Name:MAVERICK LABS LLC
Entity type:Organization
Organization Name:MAVERICK LABS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:HIRTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-504-8343
Mailing Address - Street 1:4601 N CONGRESS AVE SUITE 203
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407
Mailing Address - Country:US
Mailing Address - Phone:561-806-0990
Mailing Address - Fax:561-423-2495
Practice Address - Street 1:4601 N CONGRESS AVE SUITE 203
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407
Practice Address - Country:US
Practice Address - Phone:561-806-0990
Practice Address - Fax:561-423-2495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-14
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL800028324291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory