Healthcare Provider Details

I. General information

NPI: 1790444644
Provider Name (Legal Business Name): HEALIX RX PATHOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2021
Last Update Date: 12/08/2021
Certification Date: 11/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 CENTRAL AVE RM 202
CHEYENNE WY
82001-4575
US

IV. Provider business mailing address

1620 CENTRAL AVE RM 202
CHEYENNE WY
82001-4575
US

V. Phone/Fax

Practice location:
  • Phone: 307-635-8700
  • Fax:
Mailing address:
  • Phone: 307-635-8700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207SG0203X
TaxonomyClinical Molecular Genetics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ZC0008X
TaxonomyClinical Informatics (Pathology) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207ZP0007X
TaxonomyMolecular Genetic Pathology (Pathology) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. RONALD TAMOL JR.
Title or Position: MANAGING MEMBER
Credential:
Phone: 704-661-1500