1770980062 NPI number — SMART LAB LLC

Table of content: (NPI 1770980062)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770980062 NPI number — SMART LAB LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SMART LAB 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:
1770980062
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10385 IRONWOOD RD
Provider Second Line Business Mailing Address:
SUITE 130
Provider Business Mailing Address City Name:
PALM BEACH GARDENS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33410-4291
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-513-8440
Provider Business Mailing Address Fax Number:
561-370-6036

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10385 IRONWOOD RD
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
PALM BEACH GARDENS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33410-4291
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-513-8440
Provider Business Practice Location Address Fax Number:
561-370-6036
Provider Enumeration Date:
12/02/2014

Additional Information

Authorized Official

Authorized Official Last Name:
WAYNE
Authorized Official First Name:
JUSTIN
Authorized Official Middle Name:
MORGAN
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
561-513-8440

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)

  • Identifier: COS 00800603 . This is a "STATE LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 100049019 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0155902 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 800027631 . This is a "STATE LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1770980062 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 34458 . This is a "STATE LICENSE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: P01611847 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1025400 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 015049900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: IH908A . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com