Provider Demographics
NPI:1902343536
Name:PHYSICIANS STAT LAB EAST COAST, LLC
Entity Type:Organization
Organization Name:PHYSICIANS STAT LAB EAST COAST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-757-8747
Mailing Address - Street 1:777 37TH ST
Mailing Address - Street 2:A107
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960
Mailing Address - Country:US
Mailing Address - Phone:772-569-6000
Mailing Address - Fax:
Practice Address - Street 1:1355 37TH ST STE 401
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-7322
Practice Address - Country:US
Practice Address - Phone:772-569-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-20
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL31702004291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory