MEDICARE: SEQUENOM CENTER FOR MOLECULAR MEDICINE 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	34D2044309	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	LCO000772	OTHER	RI	STATE OF RHODE ISLAND, DOH OFFICE OF FACILITIES REGULATION, LAB LICENSE
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	34D2044309	OTHER	NC	CLIA
9	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
10	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
11	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
12	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
13	COS 00800469	OTHER	CA	STATE OF CALIFORNIA DEPT OF PUBLIC HEALTH, CLINICAL LAB LICENSE
14	033220	OTHER	PA	STATE OF PENNSYLVANIA, DOH, CLINICAL LAB PERMIT
15	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
16	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
17	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
18	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
19	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
20	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
21	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
22	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
23	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
24	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
25	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
26	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
27	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
28	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
29	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
30	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
31	2027	OTHER	MD	STATE OF MARYLAND CLINICAL LABORATORY PERMIT
32	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
33	800026876	OTHER	FL	STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, LAB LICENSE
34	8666040	OTHER		COLLEGE OF AMERICAN PATHOLOGISTS (CAP) ACCREDITATION
35	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
36	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
37	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
38	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
39	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
40	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
41	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
42	C201222100195-1	OTHER	NC	NORTH CAROLINA CERTIFICATE OF AUTHORITY (LLC)
43	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639426281
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEQUENOM CENTER FOR MOLECULAR MEDICINE LLC

Provider Business Mailing Address
First Line	:	3595 JOHN HOPKINS CT
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-1121
Country	:	US
Telephone Number	:	858-202-9051
Fax Number	:	858-408-7847

Provider Business Practice Location Address
First Line	:	7010 KIT CREEK RD
Second Line	:	(PHYSICAL ONLY - NO USPS MAIL DELIVERY)
City	:	MORRISVILLE
State	:	NC
Zip	:	27560-9761
Country	:	US
Telephone Number	:	858-202-9051
Fax Number	:	858-408-7847

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DIRK VAN DEN BOOM
Credential	:	PHD
Telephone Number	:	858-202-9051

Provider Enumeration Date	:	08/13/2012
Last Update Date	:	03/30/2016

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