1225424294 NPI number — ATLANTIC DIAGNOSTIC LABORATORIES, LLC

Table of content: (NPI 1225424294)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225424294 NPI number — ATLANTIC DIAGNOSTIC LABORATORIES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ATLANTIC DIAGNOSTIC LABORATORIES, LLC
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:
6
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:
1225424294
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3520 PROGRESS DR STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENSALEM
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19020-5810
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-465-6763
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8419 SHARON MERCER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERCER
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16137-3169
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-685-1376
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/07/2015

Additional Information

Authorized Official

Authorized Official Last Name:
DOMENICO
Authorized Official First Name:
AARON
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
267-525-2470

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  39D2069737 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1030010040001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com