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General NPI Number Information
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NPI Number | 1225390990
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Entity Type | Organization
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Legal Business Name | ADVANTAGE TOXICOLOGY MANAGEMENT, LLC
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Dates
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Enumeration Date | 06/08/2012
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Last Update Date | 01/13/2015
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Provider Practice Location Address
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Address Line | 297 KINGSBURY GRADE SUITE 100, MAIL BOX 4470
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City | STATELINE
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State | NV
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Zip | 89449-9804
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Country | US
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Telephone | 702-598-5596
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Fax |
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Provider Business Mailing Address
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Address Line | 1801 W OLYMPIC BLVD FILE 1560
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City | PASADENA
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State | CA
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Zip | 91199-1560
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Country | US
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Telephone | 702-498-5596
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | MR. JOHN MIADICH
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Credential |
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Telephone | 702-498-5596
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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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