1043936297 NPI number — DISTINCTIVE DIAGNOSTICS LABORATORY

Table of content: (NPI 1043936297)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043936297 NPI number — DISTINCTIVE DIAGNOSTICS LABORATORY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DISTINCTIVE DIAGNOSTICS LABORATORY
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:
6
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:
1043936297
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1301 YORK RD FL 8
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUTHERVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21093-6035
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-410-9508
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 YORK RD STE 800
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUTHERVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21093-6011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-410-9508
Provider Business Practice Location Address Fax Number:
800-410-9508
Provider Enumeration Date:
10/18/2022

Additional Information

Authorized Official

Authorized Official Last Name:
BEASLEY
Authorized Official First Name:
STACI
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO/OWNER
Authorized Official Telephone Number:
717-881-0575

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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