1336497072 NPI number — SYNERGY DIAGNOSTIC LABORATORY INC

Table of content: (NPI 1336497072)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336497072 NPI number — SYNERGY DIAGNOSTIC LABORATORY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SYNERGY DIAGNOSTIC LABORATORY 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:
1336497072
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4081 SW 47TH AVE
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
DAVIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33314-4008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-581-3959
Provider Business Mailing Address Fax Number:
954-541-3952

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4081 SW 47TH AVE
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
DAVIE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33314-4008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-581-3959
Provider Business Practice Location Address Fax Number:
954-530-6331
Provider Enumeration Date:
08/28/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MUSKAT
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
954-581-3959

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , 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: 016144900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com