Healthcare Provider Details

I. General information

NPI: 1477073419
Provider Name (Legal Business Name): REPROGENETICS OREGON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2017
Last Update Date: 06/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 SW 15TH AVE
PORTLAND OR
97205-1907
US

IV. Provider business mailing address

10 FRANKLINS WAY
GUILFORD CT
06437-2193
US

V. Phone/Fax

Practice location:
  • Phone: 203-601-5200
  • Fax:
Mailing address:
  • Phone: 203-453-7416
  • Fax: 203-453-7416

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: MR. ALAN TUCKER
Title or Position: CFO
Credential:
Phone: 203-601-9808