1770977951 NPI number — INTEGRATED MOLECULAR DIAGNOSTICS PATHOLOGY, INC.

Table of content: (NPI 1770977951)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770977951 NPI number — INTEGRATED MOLECULAR DIAGNOSTICS PATHOLOGY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTEGRATED MOLECULAR DIAGNOSTICS PATHOLOGY, INC.
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:
1770977951
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 THE ALAMEDA
Provider Second Line Business Mailing Address:
STE 530
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95126-1437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-818-4051
Provider Business Mailing Address Fax Number:
866-550-3288

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12635 E MONTVIEW BLVD
Provider Second Line Business Practice Location Address:
STE 360
Provider Business Practice Location Address City Name:
AURORA
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80045-7335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-961-1773
Provider Business Practice Location Address Fax Number:
866-550-3288
Provider Enumeration Date:
03/25/2015

Additional Information

Authorized Official

Authorized Official Last Name:
VILLASENSOR
Authorized Official First Name:
ISRAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE VICE PRESIDENT/SECRETARY
Authorized Official Telephone Number:
831-818-4051

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  195377 , registered in the state of CO ; 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)





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