Provider Demographics
NPI:1417250945
Name:INTERPACE DIAGNOSTICS LAB, INC.
Entity Type:Organization
Organization Name:INTERPACE DIAGNOSTICS LAB, INC.
Other - Org Name:JS GENETICS, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:GRAHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MIAO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:862-207-7824
Mailing Address - Street 1:2 CHURCH ST S
Mailing Address - Street 2:SUITE B-05
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1717
Mailing Address - Country:US
Mailing Address - Phone:203-252-3558
Mailing Address - Fax:203-624-5742
Practice Address - Street 1:2 CHURCH ST S
Practice Address - Street 2:SUITE B-05
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1717
Practice Address - Country:US
Practice Address - Phone:203-252-3558
Practice Address - Fax:203-624-5742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-06
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCL-0664291U00000X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
D300076340OtherMEDICARE PTAN
CT07D1091103OtherCLIA