1285707943 NPI number — INDEPENDENT CLINICAL LABORATORIES LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285707943 NPI number — INDEPENDENT CLINICAL LABORATORIES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDEPENDENT CLINICAL 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:
1285707943
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/04/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22 WESTEDGE ST STE 800
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29403-6984
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
854-429-1069
Provider Business Mailing Address Fax Number:
833-247-4091

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3110 CHERRY PALM DR
Provider Second Line Business Practice Location Address:
SUITE 340
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33619-8304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-932-0374
Provider Business Practice Location Address Fax Number:
813-931-0658
Provider Enumeration Date:
11/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NODES
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
843-754-7748

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  800001312 , 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: 030103500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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