Healthcare Provider Details

I. General information

NPI: 1659672004
Provider Name (Legal Business Name): ESOTERIX GENETIC LABORATORIES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2010
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533 W 57TH ST
NEW YORK NY
10019-2901
US

IV. Provider business mailing address

PO BOX 2240
BURLINGTON NC
27216-2240
US

V. Phone/Fax

Practice location:
  • Phone: 212-698-0300
  • Fax:
Mailing address:
  • Phone: 800-222-7566
  • Fax: 336-436-1048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY WILLIAMS
Title or Position: VP
Credential:
Phone: 800-222-7566