=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730357658
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROPRIUS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2008
-----------------------------------------------------
Last Update Date | 02/13/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12264 EL CAMINO REAL STE 350
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92130-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-436-1816
-----------------------------------------------------
Fax | 858-259-8941
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12264 EL CAMINO REAL STE 350
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92130-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-436-1816
-----------------------------------------------------
Fax | 858-259-8941
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MR. MICHAEL J. WALSH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 858-436-1803
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------