1982202453 NPI number — BEECHTREE MOLECULAR LAB 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 1982202453 NPI number — BEECHTREE MOLECULAR LAB LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEECHTREE MOLECULAR LAB 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:
BT MOLECULAR LLC
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:
1982202453
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/28/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12351 S GATEWAY PARK PL STE D-700
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DRAPER
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84020-9581
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-893-2773
Provider Business Mailing Address Fax Number:
801-683-9907

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12351 S GATEWAY PARK PLACE
Provider Second Line Business Practice Location Address:
SUITE D-500
Provider Business Practice Location Address City Name:
DRAPER
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84020-8402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-998-0866
Provider Business Practice Location Address Fax Number:
801-683-9907
Provider Enumeration Date:
10/15/2020

Additional Information

Authorized Official

Authorized Official Last Name:
DAWSON
Authorized Official First Name:
GARY
Authorized Official Middle Name:
Authorized Official Title or Position:
VP OF FINANCE
Authorized Official Telephone Number:
801-893-2773

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: 46D2209724 . This is a "CLIA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 02D2195732 . This is a "CLIA" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".




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