MEDICARE: AFFILIATED GENETICS, INC.

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	11808800-002-STC	UT

General Provider Information

NPI Number	:	1255770491
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AFFILIATED GENETICS, INC.

Provider Business Mailing Address
First Line	:	2749 E PARLEYS WAY
Second Line	:	SUITE 100
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-1660
Country	:	US
Telephone Number	:	801-582-4200
Fax Number	:	801-582-8460

Provider Business Practice Location Address
First Line	:	2749 E PARLEYS WAY
Second Line	:	SUITE 100
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-1660
Country	:	US
Telephone Number	:	801-582-4200
Fax Number	:	801-582-8460

Authorized Official
Title or Position	:	CHIEF MEDICAL OFFICER
Name	:	DR. KENNETH WARD
Credential	:	M.D.
Telephone Number	:	801-582-4200

Provider Enumeration Date	:	06/20/2013
Last Update Date	:	07/02/2013

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