Provider Demographics
NPI:1265854855
Name:GENETIC TECHNOLOGICAL INNOVATIONS, LLC
Entity Type:Organization
Organization Name:GENETIC TECHNOLOGICAL INNOVATIONS, LLC
Other - Org Name:GENETIC TECHNOLOGICAL INNOVATIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:GLIMCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-476-8761
Mailing Address - Street 1:14500 N NORTHSIGHT BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-3659
Mailing Address - Country:US
Mailing Address - Phone:877-993-2484
Mailing Address - Fax:480-265-4453
Practice Address - Street 1:13402 N SCOTTSDALE RD STE 183
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-4054
Practice Address - Country:US
Practice Address - Phone:480-674-6565
Practice Address - Fax:480-265-4453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-15
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05D2071616291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100347080Medicaid
TX3964041Medicaid