Provider Demographics
NPI:1083678205
Name:FLORIDA DEPARTMENT OF HEALTH
Entity type:Organization
Organization Name:FLORIDA DEPARTMENT OF HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BIOLOGICAL ADMINISTRATOR III
Authorized Official - Prefix:MR
Authorized Official - First Name:JESUS
Authorized Official - Middle Name:EDGARDO
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-514-5360
Mailing Address - Street 1:PO BOX 29
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33402-0029
Mailing Address - Country:US
Mailing Address - Phone:561-514-5360
Mailing Address - Fax:561-514-5550
Practice Address - Street 1:1150 45TH ST
Practice Address - Street 2:ROOM L-200
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-2361
Practice Address - Country:US
Practice Address - Phone:561-514-5360
Practice Address - Fax:561-514-5550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-14
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL800001191291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL030448400Medicaid
FL030448400Medicaid