=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669746079
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRAGEN, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2012
-----------------------------------------------------
Last Update Date | 09/23/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 485 MASSACHUSETTS AVE SUITE 300
-----------------------------------------------------
City | CAMBRIDGE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02139-4081
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-992-7475
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 485 MASSACHUSETTS AVE SUITE 300
-----------------------------------------------------
City | CAMBRIDGE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02139-4081
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-992-7475
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL MANAGER
-----------------------------------------------------
Name | MR. LARRY YOST
-----------------------------------------------------
Credential | R.PH.
-----------------------------------------------------
Telephone | 877-992-7475
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------