Provider Demographics
NPI:1528205028
Name:SEQUENOM CENTER FOR MOLECULAR MEDICINE LLC
Entity Type:Organization
Organization Name:SEQUENOM CENTER FOR MOLECULAR MEDICINE LLC
Other - Org Name:SEQUENOM LABORATORIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DIRK
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN DEN BOOM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:858-202-9051
Mailing Address - Street 1:3595 JOHN HOPKINS CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1121
Mailing Address - Country:US
Mailing Address - Phone:858-202-9051
Mailing Address - Fax:858-408-7847
Practice Address - Street 1:301 MICHIGAN ST NE STE 580
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3314
Practice Address - Country:US
Practice Address - Phone:858-202-9051
Practice Address - Fax:858-408-7847
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SEQUENOM INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-21
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACOS800270OtherCLINICAL LABORATORY LICENSE
MI23D1054909OtherCLIA
PA031049OtherCLINICAL LABORATORY PERMIT
MD1571OtherMEDICAL LABORATORY PERMIT
NYPFI8599OtherCLINICAL LABORATORY PERMIT
CACOS800270OtherCLINICAL LABORATORY LICENSE
RILCO00546OtherLABORATORY LICENSE
MT1528205028Medicaid
WY1528205028Medicaid
UT1528205028Medicaid
WI1528205028Medicaid
LA2142381Medicaid
NH30808279Medicaid
TX323815601Medicaid
HI647034Medicaid
CO78188253Medicaid
AKLB001MIMedicaid
TN1518576Medicaid
SC1528205028Medicaid
ID1528205028Medicaid
DC46533100Medicaid
WA1528205028Medicaid
NC7001397Medicaid
MS01039871Medicaid
MI23D1054909OtherCLIA
OK200311320AMedicaid
NM67353045Medicaid
NJ0233145Medicaid
VA1528205028Medicaid
MO1528205028Medicaid
KS20065670AMedicaid
AL121042Medicaid
NE10025870000Medicaid
FL80025109OtherCLINICAL LABORATORY LICENSE
PA031049OtherCLINICAL LABORATORY PERMIT
MI1528205028Medicaid
KY1528205028Medicaid
MD4192451 00Medicaid
AZ468862Medicaid
OR500645432Medicaid
IL770365889001Medicaid
GA142587574AMedicaid
FL001766700Medicaid
MI1528205028Medicare PIN
MD1571OtherMEDICAL LABORATORY PERMIT
NYPFI8599OtherCLINICAL LABORATORY PERMIT
IN200958790 AMedicaid
WV3810018408Medicaid
AK1006827Medicaid
PAMA1023776950001Medicaid