MEDICARE: DAVINCI INNOVATIONS, 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	L13000030595	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	45D2069185	OTHER	TX	CLIA#
2	23D2071783	OTHER	MI	CLIA#
3	49D2069987	OTHER	VA	CLIA#

General Provider Information

NPI Number	:	1275876591
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVINCI INNOVATIONS, LLC

Provider Business Mailing Address
First Line	:	PO BOX 847090
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02284-7090
Country	:	US
Telephone Number	:	844-384-5887
Fax Number	:	807-270-7384

Provider Business Practice Location Address
First Line	:	9150 MAIN ST
Second Line	:	SUITE C
City	:	HOUSTON
State	:	TX
Zip	:	77025-3843
Country	:	US
Telephone Number	:	844-384-5887
Fax Number	:	807-270-7384

Authorized Official
Title or Position	:	CEO
Name	:	MRS. LAURA ANN MILLER
Credential	:
Telephone Number	:	518-598-7272

Provider Enumeration Date	:	04/04/2013
Last Update Date	:	03/04/2014

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Directions to “DAVINCI INNOVATIONS, LLC ” Practice Location

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