Provider Demographics
NPI:1952730764
Name:STATLAB MOBILE LLC
Entity Type:Organization
Organization Name:STATLAB MOBILE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHEVERAL
Authorized Official - Middle Name:
Authorized Official - Last Name:DEACON
Authorized Official - Suffix:
Authorized Official - Credentials:ASPT
Authorized Official - Phone:305-491-3809
Mailing Address - Street 1:19101 SW 108TH AVE UNIT 4
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-6783
Mailing Address - Country:US
Mailing Address - Phone:844-469-5227
Mailing Address - Fax:
Practice Address - Street 1:19101 SW 108TH AVE UNIT 4
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-6783
Practice Address - Country:US
Practice Address - Phone:844-469-5227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-03
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016241900Medicaid
FLIJ997Medicare UPIN