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General NPI Number Information
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NPI Number | 1194205260
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Entity Type | Organization
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Legal Business Name | RENOVA DIAGNOSTICS LLC
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Dates
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Enumeration Date | 08/17/2018
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Last Update Date | 12/18/2018
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Provider Practice Location Address
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Address Line | 9318 N 95TH WAY STE A-205
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City | SCOTTSDALE
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State | AZ
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Zip | 85258-5537
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Country | US
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Telephone | 480-299-7442
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Fax |
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Provider Business Mailing Address
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Address Line | 9318 N 95TH WAY STE A-205
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City | SCOTTSDALE
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State | AZ
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Zip | 85258-5537
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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 | OWNER
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Name | JOHN GRAKO
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Credential |
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Telephone | 480-299-7442
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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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