1790274678 NPI number — HERITAGE LABS, INC.

Table of content: (NPI 1790274678)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790274678 NPI number — HERITAGE LABS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HERITAGE LABS, INC.
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:
ION DIAGNOSTICS 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:
1790274678
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30600 TELEGRAPH RD STE 1375
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BINGHAM FARMS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48025-4589
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-535-8088
Provider Business Mailing Address Fax Number:
877-466-6399

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1883 HICKS RD STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROLLING MEADOWS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60008-1255
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-327-7800
Provider Business Practice Location Address Fax Number:
877-466-6399
Provider Enumeration Date:
05/06/2018

Additional Information

Authorized Official

Authorized Official Last Name:
KIMINAIA
Authorized Official First Name:
NAMEER
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
616-327-7800

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)

  • Identifier: 14D2258031 . This is a "CLIA IDENTIFICATION NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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