1396202602 NPI number — BEECHTREE DIAGNOSTICS LLP

Table of content: (NPI 1396202602)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396202602 NPI number — BEECHTREE DIAGNOSTICS LLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEECHTREE DIAGNOSTICS LLP
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:
1396202602
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 35146
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98124-5146
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:
41818 N VENTURE DR STE 150
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANTHEM
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85086-3190
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-881-7810
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/22/2019

Additional Information

Authorized Official

Authorized Official Last Name:
CHAMBERS
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
SEAMAN-HYATT
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
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: 46D2103212 . This is a "CLIA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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