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General NPI Number Information
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NPI Number | 1174900187
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Entity Type | Organization
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Legal Business Name | SPECTOX LABS LLC
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Dates
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Enumeration Date | 04/28/2015
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Last Update Date | 08/12/2015
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Provider Practice Location Address
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Address Line | 10850 DOVER ST SUITE 900
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City | WESTMINSTER
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State | CO
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Zip | 80021-2652
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Country | US
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Telephone | 303-515-7234
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Fax |
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Provider Business Mailing Address
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Address Line | 23016 LAKE FOREST DR SUITE A-398
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City | LAGUNA HILLS
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State | CA
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Zip | 92653-1324
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Country | US
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Telephone | 303-515-7234
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | JEREMY M BRODERICK
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Credential |
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Telephone | 303-515-7234
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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 | 06D2099282
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License Number State | CO
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