Basic Information
| Provider Information | |||||||||
| NPI: | 1467602805 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IDEAL LABS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 144333 | ||||||||
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| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328144333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074229831 | ||||||||
| FaxNumber: | 4076482065 | ||||||||
| Practice Location | |||||||||
| Address1: | 307 HAMBURG TPKE | ||||||||
| Address2: | |||||||||
| City: | WAYNE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074702142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739563589 | ||||||||
| FaxNumber: | 9757205733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2008 | ||||||||
| LastUpdateDate: | 03/30/2009 | ||||||||
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| AuthorizedOfficialLastName: | ESPINAL-MARIOTTE | ||||||||
| AuthorizedOfficialFirstName: | JOSE | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9739563589 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 0003305 | NJ | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.