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General NPI Number Information
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NPI Number | 1992998157
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Entity Type | Organization
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Legal Business Name | IVERSON GENETIC DIAGNOSTICS, INC.
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Dates
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Enumeration Date | 08/21/2007
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Last Update Date | 11/02/2016
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Provider Practice Location Address
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Address Line | 645 MEETING STREET
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City | CHARLESTON
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State | SC
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Zip | 29403
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Country | US
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Telephone | 843-789-5912
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Fax | 888-909-9784
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Provider Business Mailing Address
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Address Line | 645 MEETING STREET
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City | CHARLESTON
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State | SC
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Zip | 29403
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Country | US
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Telephone | 843-789-5912
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Fax | 888-909-9784
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Authorized Official
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Title or Position | CEO
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Name | MR. JOSEPH CLOUSE
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Credential |
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Telephone | 720-284-7526
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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 | MTS-5156
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License Number State | WA
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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 | MTSC.FS.600017885
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License Number State | WA
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