Provider Demographics
NPI:1003366964
Name:IMMUNETECH, INC
Entity Type:Organization
Organization Name:IMMUNETECH, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-717-8064
Mailing Address - Street 1:3856 BAY CENTER PL
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94545-3619
Mailing Address - Country:US
Mailing Address - Phone:650-312-1066
Mailing Address - Fax:888-275-3505
Practice Address - Street 1:3856 BAY CENTER PL
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94545-3619
Practice Address - Country:US
Practice Address - Phone:650-312-1066
Practice Address - Fax:888-275-3505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF 11721291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1952601593OtherMEDICARE NPI