Provider Demographics
NPI: | 1205215597 |
---|---|
Name: | PROSYNTHESIS LABORATORIES, INC. |
Entity Type: | Organization |
Organization Name: | PROSYNTHESIS LABORATORIES, INC. |
Other - Org Name: | UNJURY PROTEIN |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JEROME |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | KRACHENFELS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 703-625-1000 |
Mailing Address - Street 1: | 45975 NOKES BLVD |
Mailing Address - Street 2: | STE 170 |
Mailing Address - City: | STERLING |
Mailing Address - State: | VA |
Mailing Address - Zip Code: | 20166-6554 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 703-430-2221 |
Mailing Address - Fax: | 703-430-8886 |
Practice Address - Street 1: | 45975 NOKES BLVD |
Practice Address - Street 2: | STE 170 |
Practice Address - City: | STERLING |
Practice Address - State: | VA |
Practice Address - Zip Code: | 20166-6554 |
Practice Address - Country: | US |
Practice Address - Phone: | 703-430-2221 |
Practice Address - Fax: | 703-430-8886 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2015-05-20 |
Last Update Date: | 2015-05-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 332BP3500X | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition |