Healthcare Provider Details

I. General information

NPI: 1447022819
Provider Name (Legal Business Name): NXGEN MDX, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2023
Last Update Date: 10/27/2023
Certification Date: 10/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 BROADWAY AVE NW STE 203
GRAND RAPIDS MI
49504-4463
US

IV. Provider business mailing address

801 BROADWAY AVE NW STE 203
GRAND RAPIDS MI
49504-4463
US

V. Phone/Fax

Practice location:
  • Phone: 855-776-9436
  • Fax: 616-710-4667
Mailing address:
  • Phone: 855-776-9436
  • Fax: 616-710-4667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QG0250X
TaxonomyGenetics Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALAN MACK
Title or Position: CEO
Credential:
Phone: 847-343-0402