Provider Demographics
NPI:1083280978
Name:INGENIOUS PERSONALIZED MEDICINE, LLC
Entity Type:Organization
Organization Name:INGENIOUS PERSONALIZED MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:SEGAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:888-852-6672
Mailing Address - Street 1:1065 NE 125TH STREET
Mailing Address - Street 2:SUITE 300
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-5833
Mailing Address - Country:US
Mailing Address - Phone:786-221-1734
Mailing Address - Fax:305-891-4228
Practice Address - Street 1:6915 TUTT BOULEVARD
Practice Address - Street 2:SUITE 110A
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80923-3591
Practice Address - Country:US
Practice Address - Phone:786-221-1734
Practice Address - Fax:305-891-4228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-01
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory