Provider Demographics
NPI:1386615730
Name:FLORIDA CLINICAL LAB,INC
Entity type:Organization
Organization Name:FLORIDA CLINICAL LAB,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:DELIGDISH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-727-3495
Mailing Address - Street 1:27 E HIBISCUS BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3171
Mailing Address - Country:US
Mailing Address - Phone:321-308-0868
Mailing Address - Fax:321-308-0873
Practice Address - Street 1:27 E HIBISCUS BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3171
Practice Address - Country:US
Practice Address - Phone:321-308-0868
Practice Address - Fax:321-308-0873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-01
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL800017966291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL690009481OtherRAILROAD MEDICARE
FL500004100Medicaid
FLL9236OtherBLUE CROSS BLUE SHIELD
FLE9112Medicare PIN