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General NPI Number Information
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NPI Number | 1417250945
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Entity Type | Organization
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Legal Business Name | INTERPACE DIAGNOSTICS LAB, INC.
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Dates
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Enumeration Date | 12/06/2010
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Last Update Date | 04/22/2015
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Provider Practice Location Address
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Address Line | 2 CHURCH ST S SUITE B-05
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City | NEW HAVEN
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State | CT
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Zip | 06519-1717
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Country | US
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Telephone | 203-252-3558
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Fax | 203-624-5742
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Provider Business Mailing Address
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Address Line | 2 CHURCH ST S SUITE B-05
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City | NEW HAVEN
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State | CT
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Zip | 06519-1717
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Country | US
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Telephone | 203-252-3558
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Fax | 203-624-5742
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Authorized Official
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Title or Position | CFO
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Name | MR. GRAHAM MIAO
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Credential |
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Telephone | 862-207-7824
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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 | CL-0664
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License Number State | CT
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Taxonomy #2
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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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