Provider Demographics
NPI:1578951901
Name:DOMINION DIAGNOSTICS LLC
Entity Type:Organization
Organization Name:DOMINION DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCSALLY
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:401-667-0868
Mailing Address - Street 1:211 CIRCUIT DR
Mailing Address - Street 2:
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-7440
Mailing Address - Country:US
Mailing Address - Phone:877-734-9600
Mailing Address - Fax:401-667-0330
Practice Address - Street 1:706 GREEN VALLEY RD
Practice Address - Street 2:SUITE 105
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7038
Practice Address - Country:US
Practice Address - Phone:877-734-9600
Practice Address - Fax:401-667-0330
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DOMINION DIAGNOSTICS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC34D2089118OtherCLIA REGISTRATION