1043658966 NPI number — INDIVIDUALIZED TREATMENT TECHNOLOGIES LABORATORIES, LLC

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043658966 NPI number — INDIVIDUALIZED TREATMENT TECHNOLOGIES LABORATORIES, LLC

Employer Identification Number (EIN):

Provider Organization Name:

INDIVIDUALIZED TREATMENT TECHNOLOGIES LABORATORIES, LLC

Provider Last Name:

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NPI Number:

1043658966

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

04/05/2017

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

303 WILLIAMS AVE SW

Provider Second Line Business Mailing Address:

SUITE 135

Provider Business Mailing Address City Name:

HUNTSVILLE

Provider Business Mailing Address State Name:

AL

Provider Business Mailing Address Postal Code:

35801-6012

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

855-436-6728

Provider Business Mailing Address Fax Number:

256-489-7134

Provider First Line Business Practice Location Address:

2705 ARTIE ST SW

Provider Second Line Business Practice Location Address:

BUILDING 400 SUITE 25

Provider Business Practice Location Address City Name:

HUNTSVILLE

Provider Business Practice Location Address State Name:

AL

Provider Business Practice Location Address Postal Code:

35805-4761

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

256-434-5160

Provider Business Practice Location Address Fax Number:

205-930-0082

Provider Enumeration Date:

06/13/2013

Authorized Official Last Name:

STODDARD

Authorized Official First Name:

JOHNNY

Authorized Official Middle Name:

L.

Authorized Official Title or Position:

PRESIDENT AND CEO

Authorized Official Telephone Number:

256-714-2105

• Taxonomy code: 291U00000X , with the licence number:  L37174 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 291U00000X , with the licence number: L45100 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 0544256 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
• Identifier: 08976741 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
• Identifier: 1043658966 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
• Identifier: 3578338 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 82987564 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
• Identifier: 103155 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
• Identifier: 185597 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
• Identifier: 201369650A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: 212246709 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
• Identifier: L00494 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
• Identifier: 1043658966 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
• Identifier: 7100419330 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".