MEDICARE: IMPRESSIVE DIAGNOSTICS

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	247ZC0005X	Clinical Laboratory Director (Non-physician)		LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	19D2148153	OTHER	LA	CLINICAL LABORATORY IMPROVEMENT AMENDMENTS

General Provider Information

NPI Number	:	1407349095
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPRESSIVE DIAGNOSTICS

Provider Business Mailing Address
First Line	:	7011 READ BLVD STE I
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70127-2244
Country	:	US
Telephone Number	:	504-209-1906
Fax Number	:

Provider Business Practice Location Address
First Line	:	7011 READ BLVD STE I
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70127
Country	:	US
Telephone Number	:	504-209-1906
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATIVE MANAGER
Name	:	KENDALYN N MARSHALL
Credential	:
Telephone Number	:	504-209-1906

Provider Enumeration Date	:	06/08/2018
Last Update Date	:	06/08/2018

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Directions to “IMPRESSIVE DIAGNOSTICS ” Practice Location

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