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General NPI Number Information
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NPI Number | 1891811931
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Entity Type | Organization
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Legal Business Name | IDAHO CYTOGENETICS DIAGNOSTIC LAB
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Dates
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Enumeration Date | 03/21/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2220 OLD PENITENTIARY RD STE 16
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City | BOISE
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State | ID
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Zip | 83712-8249
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Country | US
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Telephone | 208-376-8585
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 78
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City | BOISE
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State | ID
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Zip | 83707-0078
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Country | US
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Telephone | 208-376-8585
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Fax |
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Authorized Official
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Title or Position | BILLING MANAGER
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Name | MRS. SANDI K BEACH
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Credential |
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Telephone | 509-755-8700
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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 |
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License Number State | ID
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