Organization
ST JOHNS BIOMEDICAL LABORATORIES INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
EDWIN OLIVA SIA MD, BCLD(ABB) (DIRECTOR/OWNER)
(904) 824-5497
Entity
Organization
Contact information
Practice address
165 SOUTHPARK BLVD, SUITE A, ST AUGUSTINE, FL 32086-4101
(904) 824-5497
(904) 824-8257
Mailing address
PO BOX 860206, 165 SOUTHPARK BLVD, ST. AUGUSTINE, FL 32086-0206
(904) 824-5497
(904) 824-8257
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
Primary
800001722
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
030142600
—
FL
01
—
10D0645082
CLIA
FL
01
—
800001722
CLINICAL LAB LICENSE
FL
Enumeration date
08/14/2006
Last updated
06/17/2008
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