Healthcare Provider Details

I. General information

NPI: 1629713748
Provider Name (Legal Business Name): NVIRA GENETICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2022
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 DOUGLAS AVE
RACINE WI
53402-4316
US

IV. Provider business mailing address

2510 DOUGLAS AVE
RACINE WI
53402-4316
US

V. Phone/Fax

Practice location:
  • Phone: 262-705-9900
  • Fax:
Mailing address:
  • Phone: 262-622-6260
  • Fax:

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: RANDY MUSAITEF
Title or Position: ADMIN
Credential:
Phone: 262-705-9900