1083280978 NPI number — INGENIOUS PERSONALIZED MEDICINE, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083280978 NPI number — INGENIOUS PERSONALIZED MEDICINE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INGENIOUS PERSONALIZED MEDICINE, 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:
1083280978
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1065 NE 125TH STREET
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
NORTH MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33161-5833
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-221-1734
Provider Business Mailing Address Fax Number:
305-891-4228

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6915 TUTT BOULEVARD
Provider Second Line Business Practice Location Address:
SUITE 110A
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80923-3591
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-221-1734
Provider Business Practice Location Address Fax Number:
305-891-4228
Provider Enumeration Date:
06/01/2021

Additional Information

Authorized Official

Authorized Official Last Name:
SEGAL
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
DANIEL
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
888-852-6672

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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