MEDICARE: DNA ANALYTICAL LABORATORY LV LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1164019725
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DNA ANALYTICAL LABORATORY LV LLC

Provider Business Mailing Address
First Line	:	4310 CAMERON ST STE 9
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-3826
Country	:	US
Telephone Number	:	702-550-0124
Fax Number	:	702-675-8122

Provider Business Practice Location Address
First Line	:	4310 CAMERON ST STE 9
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-3826
Country	:	US
Telephone Number	:	702-550-0124
Fax Number	:	702-675-8122

Authorized Official
Title or Position	:	DIRECTOR OF LABORATORY OPERATIONS
Name	:	MR. LISA KAPLAN
Credential	:
Telephone Number	:	469-230-7545

Provider Enumeration Date	:	12/29/2020
Last Update Date	:	03/29/2023

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