=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962093302
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARDENTECH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2021
-----------------------------------------------------
Last Update Date | 01/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3325 LONGVIEW DR
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95821-7103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-299-9956
-----------------------------------------------------
Fax | 916-299-9941
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 661414
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95866-1414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-299-9956
-----------------------------------------------------
Fax | 916-299-9941
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | SYYED ALI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 916-299-9942
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 293D00000X
-----------------------------------------------------
Taxonomy Name | Physiological Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------