Provider Demographics
NPI:1588163505
Name:CLG DIAGNOSTICS. LLC
Entity type:Organization
Organization Name:CLG DIAGNOSTICS. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF COMPLIANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-328-8633
Mailing Address - Street 1:PO BOX 1254
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:NH
Mailing Address - Zip Code:03079-1138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11350 SW VILLAGE PKWY STE 307
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2352
Practice Address - Country:US
Practice Address - Phone:603-328-8633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory