1982202453 NPI number — BEECHTREE MOLECULAR LAB LLC

Table of content: (NPI 1982202453)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982202453 NPI number — BEECHTREE MOLECULAR LAB LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEECHTREE MOLECULAR LAB 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:
1982202453
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/28/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12351 S GATEWAY PARK PL STE D-700
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DRAPER
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84020-9581
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:
12351 S GATEWAY PARK PLACE
Provider Second Line Business Practice Location Address:
SUITE D-500
Provider Business Practice Location Address City Name:
DRAPER
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84020-8402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-998-0866
Provider Business Practice Location Address Fax Number:
801-683-9907
Provider Enumeration Date:
10/15/2020

Additional Information

Authorized Official

Authorized Official Last Name:
DAWSON
Authorized Official First Name:
GARY
Authorized Official Middle Name:
Authorized Official Title or Position:
VP OF FINANCE
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: 46D2209724 . This is a "CLIA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 02D2195732 . This is a "CLIA" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".




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