Provider Demographics
NPI:1073591822
Name:GENOVA DIAGNOSTICS INC
Entity Type:Organization
Organization Name:GENOVA DIAGNOSTICS INC
Other - Org Name:GREAT SMOKIES DIAGNOSTIC LABORATORY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:LEDFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-210-7764
Mailing Address - Street 1:63 ZILLICOA ST
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28801-1038
Mailing Address - Country:US
Mailing Address - Phone:888-540-2199
Mailing Address - Fax:828-210-7321
Practice Address - Street 1:63 ZILLICOA ST
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-1038
Practice Address - Country:US
Practice Address - Phone:828-210-7321
Practice Address - Fax:828-210-7321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-03
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34D0655571291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8900489Medicaid
TN4490659Medicaid
MN543317700Medicaid
ORI54653Medicaid
ORI54653Medicaid