1205923612 NPI number — SONORA QUEST LABORATORIES LLC

Table of content: (NPI 1205923612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205923612 NPI number — SONORA QUEST LABORATORIES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SONORA QUEST LABORATORIES 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:
SONORA QUEST LABORATORIES OF TUCSON
Provider Other Organization Name Type Code:
5
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:
1205923612
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 67150
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85082-7150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-685-5000
Provider Business Mailing Address Fax Number:
602-685-5903

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
630 N ALVERNON WAY STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85711-1895
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-322-8264
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/06/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DEXTER
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
602-685-5000

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  03D0669882 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 452152 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".