=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619680675
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RCL GENOMICS CLINICAL LABORATORIES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2023
-----------------------------------------------------
Last Update Date | 01/04/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10800 E BETHANY DR STE 301
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80014-2687
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-492-1023
-----------------------------------------------------
Fax | 720-492-1033
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10800 E BETHANY DR STE 301
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80014-2687
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-492-1023
-----------------------------------------------------
Fax | 720-492-1033
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JEFFERY C COONS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 720-309-4720
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------