MEDICARE: DOMINION DIAGNOSTICS, 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	00343	RI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	49D0926092	OTHER	CLIA
2	1334975	OTHER	CAP AU-ID
3	7029901	OTHER	CAP LAP NUMBER
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912903717
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOMINION DIAGNOSTICS, LLC

Provider Business Mailing Address
First Line	:	211 CIRCUIT DRIVE
Second Line	:
City	:	NORTH KINGSTOWN
State	:	RI
Zip	:	02852-7440
Country	:	US
Telephone Number	:	877-734-9600
Fax Number	:	401-667-0330

Provider Business Practice Location Address
First Line	:	211 CIRCUIT DRIVE
Second Line	:
City	:	NORTH KINGSTOWN
State	:	RI
Zip	:	02852-7440
Country	:	US
Telephone Number	:	877-734-9600
Fax Number	:	401-667-0330

Authorized Official
Title or Position	:	PAYER RELATIONS REP
Name	:	BRANDY ELLIS
Credential	:
Telephone Number	:	802-734-6392

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	12/14/2022

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Directions to “DOMINION DIAGNOSTICS, LLC ” Practice Location

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