MEDICARE: INDIVIDUALIZED TREATMENT TECHNOLOGIES LABORATORIES

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	01D1099109	AL

General Provider Information

NPI Number	:	1548495575
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDIVIDUALIZED TREATMENT TECHNOLOGIES LABORATORIES

Provider Business Mailing Address
First Line	:	4112 AUTUMN LN
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35243-5208
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1601 12TH AVE S
Second Line	:	FIRST FLOOR
City	:	BIRMINGHAM
State	:	AL
Zip	:	35205-4709
Country	:	US
Telephone Number	:	205-930-0001
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. LEE BRUNO
Credential	:
Telephone Number	:	205-930-0001

Provider Enumeration Date	:	05/20/2009
Last Update Date	:	05/20/2009

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