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General NPI Number Information
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NPI Number | 1548495575
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Entity Type | Organization
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Legal Business Name | INDIVIDUALIZED TREATMENT TECHNOLOGIES LABORATORIES
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Dates
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Enumeration Date | 05/20/2009
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Last Update Date | 05/20/2009
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Provider Practice Location Address
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Address Line | 1601 12TH AVE S FIRST FLOOR
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City | BIRMINGHAM
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State | AL
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Zip | 35205-4709
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Country | US
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Telephone | 205-930-0001
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Fax |
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Provider Business Mailing Address
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Address Line | 4112 AUTUMN LN
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City | BIRMINGHAM
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State | AL
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Zip | 35243-5208
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | MR. LEE BRUNO
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Credential |
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Telephone | 205-930-0001
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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 | 01D1099109
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License Number State | AL
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