=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497057020
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ESOTERIX GENETIC COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2010
-----------------------------------------------------
Last Update Date | 12/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 833 CHESTNUT ST STE 1250
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19107-4414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-351-2331
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2270
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27216-2240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-222-7566
-----------------------------------------------------
Fax | 336-436-1048
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP
-----------------------------------------------------
Name | MR. KIMBERLY WILLIAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 800-222-7566
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------