1912903717 NPI number — DOMINION DIAGNOSTICS, LLC

Table of content: (NPI 1912903717)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912903717 NPI number — DOMINION DIAGNOSTICS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOMINION DIAGNOSTICS, 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:
Provider Other Organization Name Type Code:
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:
1912903717
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
211 CIRCUIT DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH KINGSTOWN
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02852-7440
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-734-9600
Provider Business Mailing Address Fax Number:
401-667-0330

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
211 CIRCUIT DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH KINGSTOWN
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02852-7440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-734-9600
Provider Business Practice Location Address Fax Number:
401-667-0330
Provider Enumeration Date:
06/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ELLIS
Authorized Official First Name:
BRANDY
Authorized Official Middle Name:
Authorized Official Title or Position:
PAYER RELATIONS REP
Authorized Official Telephone Number:
802-734-6392

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  00343 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 49D0926092 . This is a "CLIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1334975 . This is a "CAP AU-ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7029901 . This is a "CAP LAP NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 113266600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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