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General NPI Number Information
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NPI Number | 1770977951
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Entity Type | Organization
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Legal Business Name | INTEGRATED MOLECULAR DIAGNOSTICS PATHOLOGY, INC.
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Dates
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Enumeration Date | 03/25/2015
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Last Update Date | 01/25/2017
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Provider Practice Location Address
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Address Line | 12635 E MONTVIEW BLVD STE 360
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City | AURORA
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State | CO
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Zip | 80045-7335
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Country | US
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Telephone | 303-961-1773
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Fax | 866-550-3288
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Provider Business Mailing Address
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Address Line | 1900 THE ALAMEDA STE 530
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City | SAN JOSE
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State | CA
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Zip | 95126-1437
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Country | US
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Telephone | 831-818-4051
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Fax | 866-550-3288
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Authorized Official
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Title or Position | EXECUTIVE VICE PRESIDENT/SECRETARY
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Name | MR. ISRAEL VILLASENSOR
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Credential |
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Telephone | 831-818-4051
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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 | 195377
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number |
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License Number State |
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