MEDICARE: PREDICTIVE LABORATORIES, 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	207SG0203X	Clinical Molecular Genetics Physician
2	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1588229041
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREDICTIVE LABORATORIES, INC.

Provider Business Mailing Address
First Line	:	2735 E PARLEYS WAY STE 205
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-1631
Country	:	US
Telephone Number	:	855-497-3636
Fax Number	:	888-972-9124

Provider Business Practice Location Address
First Line	:	2749 E PARLEYS WAY STE 100
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-1638
Country	:	US
Telephone Number	:	855-497-3636
Fax Number	:	888-972-9124

Authorized Official
Title or Position	:	CEO
Name	:	BRADLEY C ROBINSON
Credential	:
Telephone Number	:	385-290-4504

Provider Enumeration Date	:	05/09/2019
Last Update Date	:	12/21/2020

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