Basic Information
| Provider Information | |||||||||
| NPI: | 1548706476 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INNOVATIVE LABORATORYSERVICES, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 713 E MARION AVE | ||||||||
| Address2: | SUITE 1211 | ||||||||
| City: | PUNTA GORDA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339503872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9415052100 | ||||||||
| FaxNumber: | 9415056100 | ||||||||
| Practice Location | |||||||||
| Address1: | 2654 SW 32ND PL | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344717847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9415051000 | ||||||||
| FaxNumber: | 9415056100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2017 | ||||||||
| LastUpdateDate: | 01/17/2017 | ||||||||
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| AuthorizedOfficialLastName: | RAVID | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT AND OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9415052100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 27702 | 01 | FL | COLA | OTHER |