Provider Demographics
NPI:1811441751
Name:ATLANTIC DIAGNOSTIC LABORATORIES, LLC
Entity type:Organization
Organization Name:ATLANTIC DIAGNOSTIC LABORATORIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:AARON
Authorized Official - Middle Name:A
Authorized Official - Last Name:DOMENICO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-525-2470
Mailing Address - Street 1:3520 PROGRESS DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:BENSALEM
Mailing Address - State:PA
Mailing Address - Zip Code:19020-5810
Mailing Address - Country:US
Mailing Address - Phone:267-525-0467
Mailing Address - Fax:
Practice Address - Street 1:20 QUIRK RD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-3745
Practice Address - Country:US
Practice Address - Phone:267-525-2470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-09
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCL-0764291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory