=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255376620
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHARMACOGENETICS DIAGNOSTIC LABORATORY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2006
-----------------------------------------------------
Last Update Date | 05/07/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 E JEFFERSON ST SUITE 309
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40202-1246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-569-1584
-----------------------------------------------------
Fax | 502-569-1585
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 E JEFFERSON ST SUITE 309
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40202-1246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-569-1584
-----------------------------------------------------
Fax | 502-569-1054
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP
-----------------------------------------------------
Name | MARK LINDER
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 502-569-1584
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 200251
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------