MEDICARE: NATIONAL GENETICS INSTITUTE

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	05D0935390	OTHER		CLIA

General Provider Information

NPI Number	:	1841535002
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NATIONAL GENETICS INSTITUTE

Provider Business Mailing Address
First Line	:	PO BOX 2240
Second Line	:
City	:	BURLINGTON
State	:	NC
Zip	:	27216-2240
Country	:	US
Telephone Number	:	800-222-7566
Fax Number	:

Provider Business Practice Location Address
First Line	:	2311 PONTIUS AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-1809
Country	:	US
Telephone Number	:	310-996-0036
Fax Number	:

Authorized Official
Title or Position	:	VP
Name	:	KIMBERLY WILLIAMS
Credential	:
Telephone Number	:	800-222-7566

Provider Enumeration Date	:	11/29/2012
Last Update Date	:	02/24/2014

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