Provider Demographics
NPI:1285707943
Name:INDEPENDENT CLINICAL LABORATORIES INC
Entity type:Organization
Organization Name:INDEPENDENT CLINICAL LABORATORIES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO - OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHEA
Authorized Official - Middle Name:COX
Authorized Official - Last Name:HARRELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-238-7466
Mailing Address - Street 1:22 WESTEDGE ST STE 800
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403-6984
Mailing Address - Country:US
Mailing Address - Phone:854-429-1069
Mailing Address - Fax:833-247-4091
Practice Address - Street 1:3110 CHERRY PALM DR
Practice Address - Street 2:SUITE 340
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619-8304
Practice Address - Country:US
Practice Address - Phone:813-932-0374
Practice Address - Fax:813-931-0658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL800001312291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL030103500Medicaid
FL030103500Medicaid