1255376620 NPI number — PHARMACOGENETICS DIAGNOSTIC LABORATORY LLC

Table of content: (NPI 1255376620)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255376620 NPI number — PHARMACOGENETICS DIAGNOSTIC LABORATORY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHARMACOGENETICS DIAGNOSTIC LABORATORY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PGXL LABORATORIES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255376620
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 E JEFFERSON ST
Provider Second Line Business Mailing Address:
SUITE 309
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40202-1246
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-569-1584
Provider Business Mailing Address Fax Number:
502-569-1054

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 E JEFFERSON ST
Provider Second Line Business Practice Location Address:
SUITE 309
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40202-1246
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-569-1584
Provider Business Practice Location Address Fax Number:
502-569-1585
Provider Enumeration Date:
06/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LINDER
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
VP
Authorized Official Telephone Number:
502-569-1584

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  200251 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 102795040 0001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1255376620 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2659764 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0065657 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0110438 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100262578-00 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1255376620 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500652629 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1255376620 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200970280A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00026220 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 195993709 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2338391 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 50121715 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7001484 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0380351 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1255376620 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1255376620 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1255376620 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1530585 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com