=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235533779
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REALTOX LABS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2014
-----------------------------------------------------
Last Update Date | 10/13/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 BUSINESS CENTER DR
-----------------------------------------------------
City | REISTERSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21136-1230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-833-3025
-----------------------------------------------------
Fax | 410-833-3158
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 BUSINESS CENTER DR
-----------------------------------------------------
City | REISTERSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21136-1230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-833-3025
-----------------------------------------------------
Fax | 410-833-3158
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. JOSHUA GOCHNAUER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-833-3025
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 21D2077230
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------