1609565027 NPI number — FOUNDATIONS DIAGNOSTIC LABORATORY LLC

Table of content: GINA JUNG EUN KOO OD (NPI 1437709383)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609565027 NPI number — FOUNDATIONS DIAGNOSTIC LABORATORY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUNDATIONS DIAGNOSTIC LABORATORY 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:
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:
1609565027
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1139 N CHARLOTTE AVE STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28110-2512
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
980-210-3151
Provider Business Mailing Address Fax Number:
919-276-8381

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1139 N CHARLOTTE AVE STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28110-2512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
980-210-3151
Provider Business Practice Location Address Fax Number:
919-276-8381
Provider Enumeration Date:
05/02/2023

Additional Information

Authorized Official

Authorized Official Last Name:
ALSTON
Authorized Official First Name:
WALLACE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
704-264-7793

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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