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General NPI Number Information
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NPI Number | 1164568002
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Entity Type | Organization
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Legal Business Name | IMMUNE THERAPY PRODUCTS, LLC
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Dates
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Enumeration Date | 01/29/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 25 MORNINGSTAR RD
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City | STATEN ISLAND
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State | NY
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Zip | 10303-2808
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Country | US
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Telephone | 718-556-5001
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Fax |
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Provider Business Mailing Address
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Address Line | 81 HARBOR VIEW PL
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City | STATEN ISLAND
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State | NY
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Zip | 10305-3909
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | LABORATORY DIRECTOR
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Name | DR. ROBERTA L HAYES
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Credential | PH.D.
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Telephone | 718-556-5001
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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 | PENDING
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License Number State | NY
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