1265458921 NPI number — ACCESS GENETICS, LLC

Table of content: (NPI 1265458921)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265458921 NPI number — ACCESS GENETICS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACCESS GENETICS, 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:
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:
1265458921
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1414
Provider Second Line Business Mailing Address:
MI63
Provider Business Mailing Address City Name:
MINNEAPLOIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55480-1414
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-250-4407
Provider Business Mailing Address Fax Number:
952-767-1153

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7400 FLYING CLOUD DR
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
EDEN PRAIRIE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55344-3720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-250-4407
Provider Business Practice Location Address Fax Number:
952-942-0703
Provider Enumeration Date:
07/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCGLENNEN
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
CHARLES
Authorized Official Title or Position:
PRESIDENT, MEDICAL DIRECTOR
Authorized Official Telephone Number:
952-400-7785

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  24D1033809 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 897100000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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