1730149709 NPI number — DVA LABORATORY SERVICES INC

Table of content: (NPI 1730149709)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730149709 NPI number — DVA LABORATORY SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DVA LABORATORY SERVICES INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730149709
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3951 SW 30TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33312-6816
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-626-5700
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3951 SW 30TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33312-6816
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-738-1809
Provider Business Practice Location Address Fax Number:
386-738-1706
Provider Enumeration Date:
03/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROLLO
Authorized Official First Name:
SANDY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR - PATIENT ACCOUNTING
Authorized Official Telephone Number:
386-626-5700

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  800001410 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 074432801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0016620560005 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4258046 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 702905100 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 98003700 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 37902335 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5624401 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7001058 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 748310400 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001083741 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7077761 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: XLAB01150 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0805092 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1693774 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100286750A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000008374 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000418723A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 030154000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100758150A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: L00079 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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