Provider Demographics
NPI:1154786051
Name:IBIS LABORATORY LLC
Entity type:Organization
Organization Name:IBIS LABORATORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:ACHINAPURA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:561-588-8323
Mailing Address - Street 1:806 LANTANA RD
Mailing Address - Street 2:
Mailing Address - City:LANTANA
Mailing Address - State:FL
Mailing Address - Zip Code:33462-1509
Mailing Address - Country:US
Mailing Address - Phone:561-588-8323
Mailing Address - Fax:561-275-7998
Practice Address - Street 1:11350 SW VILLAGE PKWY
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2352
Practice Address - Country:US
Practice Address - Phone:561-588-8323
Practice Address - Fax:561-275-7998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-18
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory