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General NPI Number Information
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NPI Number | 1043936297
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Entity Type | Organization
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Legal Business Name | DISTINCTIVE DIAGNOSTICS LABORATORY
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Dates
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Enumeration Date | 10/18/2022
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Last Update Date | 01/30/2023
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Provider Practice Location Address
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Address Line | 1301 YORK RD STE 800
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City | LUTHERVILLE
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State | MD
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Zip | 21093-6011
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Country | US
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Telephone | 800-410-9508
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Fax | 800-410-9508
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Provider Business Mailing Address
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Address Line | 1301 YORK RD FL 8
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City | LUTHERVILLE
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State | MD
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Zip | 21093-6035
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Country | US
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Telephone | 800-410-9508
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Fax |
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Authorized Official
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Title or Position | CEO/OWNER
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Name | MS. STACI BEASLEY
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Credential |
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Telephone | 717-881-0575
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number |
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License Number State |
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