IBR SPECIALTY CLINICAL LABORATORIES
1050 Forest Hill Road, Staten Island, New York 10314-6399 (718) 494-5293 FAX (718) 494-4835 CLIA #33D0860102 FRAGILE X MOLECULAR ANALYSIS Telephone # FAX # NPI # Telephone # FAX # Address City, State, Zip Address City, State, Zip Physician name (printed and signature) SPECIMEN TYPE ................
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