MEDICARE: SORENSON GENOMICS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1063792299
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SORENSON GENOMICS, LLC

Provider Business Mailing Address
First Line	:	2511 S WEST TEMPLE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84115-3060
Country	:	US
Telephone Number	:	801-462-1400
Fax Number	:	801-462-1404

Provider Business Practice Location Address
First Line	:	2495 S WEST TEMPLE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84115-3057
Country	:	US
Telephone Number	:	801-462-1400
Fax Number	:	801-462-1404

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	MR. DOUGLAS R. FOGG
Credential	:
Telephone Number	:	801-462-1409

Provider Enumeration Date	:	08/19/2011
Last Update Date	:	08/21/2014

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