=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235671884
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CERNOSTICS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2016
-----------------------------------------------------
Last Update Date | 12/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 S COMMONS STE 245
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15212-5359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-788-9007
-----------------------------------------------------
Fax | 855-929-0022
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2014 SAN MIGUEL DR
-----------------------------------------------------
City | FRIENDSWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77546-5913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-788-9007
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DEREK MAETZOLD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 832-974-1551
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 34818
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------