Providence Clinical Lab, LLC

Primary specialty

Clinical Medical LaboratoryTaxonomy code 291U00000X

License

1492292 Issued in NJ

Legal business name

PROVIDENCE CLINICAL LAB, LLC

Practice address

317 Ava Ave
Somerdale, NJ 08083-1603

Phone

(856) 534-5367

Fax

(856) 435-6067

NPI assigned

Sep 1, 2010

Last updated

Sep 7, 2023By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Ms. Carol Joan Evans, B.O.R ASCP CERTIFIED

Title

Chief Executive Officer

Phone

(856) 534-5367

Specialties & licenses 2

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1283299200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1694044800000",
    "number": "1346557022",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 213",
            "city": "SOMERDALE",
            "state": "NJ",
            "postal_code": "080830213",
            "telephone_number": "856-534-5367",
            "fax_number": "856-435-6067"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "317 AVA AVE",
            "city": "SOMERDALE",
            "state": "NJ",
            "postal_code": "080831603",
            "telephone_number": "856-534-5367",
            "fax_number": "856-435-6067"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE CLINICAL LAB, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-09-01",
        "last_updated": "2023-09-07",
        "status": "A",
        "authorized_official_last_name": "EVANS",
        "authorized_official_first_name": "CAROL",
        "authorized_official_middle_name": "JOAN",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "856-534-5367",
        "authorized_official_name_prefix": "Ms.",
        "authorized_official_credential": "B.O.R ASCP CERTIFIED"
    },
    "taxonomies": [
        {
            "code": "251E00000X",
            "taxonomy_group": "",
            "desc": "Home Health",
            "state": "NJ",
            "license": "1492292",
            "primary": false
        },
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": "NJ",
            "license": "1492292",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Clinical Medical Laboratory in Somerdale, NJ
• Providers in Somerdale, NJ by specialty
• Clinical Medical Laboratory in New Jersey

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 7, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.