1376206425 NPI number — INFINITE GENOMICS LLC

Table of content: (NPI 1376206425)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376206425 NPI number — INFINITE GENOMICS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INFINITE GENOMICS 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:
1376206425
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/09/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4850 NORTHSHORE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72118-5329
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-798-7100
Provider Business Mailing Address Fax Number:
501-798-7101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4850 NORTHSHORE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72118-5329
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-798-7100
Provider Business Practice Location Address Fax Number:
501-798-7101
Provider Enumeration Date:
10/15/2021

Additional Information

Authorized Official

Authorized Official Last Name:
STAGGS
Authorized Official First Name:
BRENT
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
501-798-7100

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 213897200 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 322000 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100983310 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9000203807 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0477871 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 700109508 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2276860 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 30004802830001 , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 89405889 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1376206425 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 290638709 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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