Provider Demographics
NPI:1225390990
Name:ADVANTAGE TOXICOLOGY MANAGEMENT, LLC
Entity Type:Organization
Organization Name:ADVANTAGE TOXICOLOGY MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MIADICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-498-5596
Mailing Address - Street 1:1801 W OLYMPIC BLVD
Mailing Address - Street 2:FILE 1560
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91199-1560
Mailing Address - Country:US
Mailing Address - Phone:702-498-5596
Mailing Address - Fax:
Practice Address - Street 1:297 KINGSBURY GRADE
Practice Address - Street 2:SUITE 100, MAIL BOX 4470
Practice Address - City:STATELINE
Practice Address - State:NV
Practice Address - Zip Code:89449-9804
Practice Address - Country:US
Practice Address - Phone:702-598-5596
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-08
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory