1366909921 NPI number — MINEOLA CLINICAL LABORATORY, LLC

Table of content: (NPI 1366909921)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366909921 NPI number — MINEOLA CLINICAL LABORATORY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINEOLA CLINICAL LABORATORY, 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:
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:
1366909921
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
481 EDWARD H ROSS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELMWOOD PARK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07407-3118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-791-2600
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
174 MINEOLA BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINEOLA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11501-2513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-575-4181
Provider Business Practice Location Address Fax Number:
201-791-1941
Provider Enumeration Date:
03/01/2019

Additional Information

Authorized Official

Authorized Official Last Name:
PINE WOOD
Authorized Official First Name:
JANE
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF LEGAL OFFICER
Authorized Official Telephone Number:
201-791-2600

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com