Provider Demographics
NPI:1043658966
Name:INDIVIDUALIZED TREATMENT TECHNOLOGIES LABORATORIES, LLC
Entity Type:Organization
Organization Name:INDIVIDUALIZED TREATMENT TECHNOLOGIES LABORATORIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:L
Authorized Official - Last Name:STODDARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-714-2105
Mailing Address - Street 1:303 WILLIAMS AVE SW
Mailing Address - Street 2:SUITE 135
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-6012
Mailing Address - Country:US
Mailing Address - Phone:855-436-6728
Mailing Address - Fax:256-489-7134
Practice Address - Street 1:2705 ARTIE ST SW
Practice Address - Street 2:BUILDING 400 SUITE 25
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35805-4761
Practice Address - Country:US
Practice Address - Phone:256-434-5160
Practice Address - Fax:205-930-0082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-13
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALL37174291U00000X
ALL45100291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0544256Medicaid
MS08976741Medicaid
MI1043658966Medicaid
TX3578338Medicaid
NM82987564Medicaid
AZ103155Medicaid
AL185597Medicaid
IN201369650AMedicaid
AR212246709Medicaid
SCL00494Medicaid
IL1043658966Medicaid
KY7100419330Medicaid