Provider Demographics
NPI:1285952762
Name:EAST COAST TOXICOLOGY LABORATORIES, INC.
Entity type:Organization
Organization Name:EAST COAST TOXICOLOGY LABORATORIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRUNO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:954-249-0903
Mailing Address - Street 1:2225 N UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-3611
Mailing Address - Country:US
Mailing Address - Phone:954-249-0903
Mailing Address - Fax:
Practice Address - Street 1:2225 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-3611
Practice Address - Country:US
Practice Address - Phone:954-249-0903
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-09
Last Update Date:2010-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10D2005687291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10D2005687Medicare UPIN