1760775886 NPI number — TREASURE COAST PATHOLOGY LAB LLC

Table of content: BRETT WILSON DO (NPI 1881662963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760775886 NPI number — TREASURE COAST PATHOLOGY LAB LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TREASURE COAST PATHOLOGY LAB LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
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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:
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NPI Number Information

NPI Number:
1760775886
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
275 18TH STREET
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
VERO BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32960-5541
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-299-5005
Provider Business Mailing Address Fax Number:
772-299-1340

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
275 18TH STREET
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
VERO BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32960-5541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-299-5005
Provider Business Practice Location Address Fax Number:
772-299-1340
Provider Enumeration Date:
05/23/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MEDALIE
Authorized Official First Name:
NEIL
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
LAB DIRECTOR
Authorized Official Telephone Number:
772-567-7088

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)





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