Provider Demographics
| NPI: | 1639426281 |
|---|---|
| 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: | |
| 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: | 7010 KIT CREEK RD |
| Practice Address - Street 2: | (PHYSICAL ONLY - NO USPS MAIL DELIVERY) |
| Practice Address - City: | MORRISVILLE |
| Practice Address - State: | NC |
| Practice Address - Zip Code: | 27560-9761 |
| 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: | 2012-08-13 |
| Last Update Date: | 2016-03-30 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| NC | 34D2044309 | 291U00000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization |
|---|---|---|---|---|
| Yes | 291U00000X | Laboratories | Clinical Medical Laboratory |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| MI | 1639426281 | Medicaid | |
| IA | 1639426281 | Medicaid | |
| AZ | 468862 | Medicaid | |
| SC | L00366 | Medicaid | |
| RI | LCO000772 | Other | STATE OF RHODE ISLAND, DOH OFFICE OF FACILITIES REGULATION, LAB LICENSE |
| NE | 100263398-00 | Medicaid | |
| ME | 1639426281 | Medicaid | |
| NC | 34D2044309 | Other | CLIA |
| NC | 7001489 | Medicaid | |
| PA | MA102377695-003 | Medicaid | |
| TX | 323804001 | Medicaid | |
| WV | 3910005749 | Medicaid | |
| CA | COS 00800469 | Other | STATE OF CALIFORNIA DEPT OF PUBLIC HEALTH, CLINICAL LAB LICENSE |
| PA | 033220 | Other | STATE OF PENNSYLVANIA, DOH, CLINICAL LAB PERMIT |
| AZ | 853726 | Medicaid | |
| OH | 0080201 | Medicaid | |
| MS | 06785780 | Medicaid | |
| WA | 1639426281 | Medicaid | |
| UT | 1639426281 | Medicaid | |
| OK | 200311320 C | Medicaid | |
| KS | 200656570D | Medicaid | |
| IN | 200958790C | Medicaid | |
| NH | 3089901 | Medicaid | |
| CO | 38871564 | Medicaid | |
| KY | 7100257370 | Medicaid | |
| FL | 9921200 | Medicaid | |
| GA | 003131635A | Medicaid | |
| DC | 085542800 | Medicaid | |
| VT | 1023532 | Medicaid | |
| WI | 1639426281 | Medicaid | |
| MD | 2027 | Other | STATE OF MARYLAND CLINICAL LABORATORY PERMIT |
| IL | 770365889-003 | Medicaid | |
| FL | 800026876 | Other | STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, LAB LICENSE |
| 8666040 | Other | COLLEGE OF AMERICAN PATHOLOGISTS (CAP) ACCREDITATION | |
| NJ | 0348244 | Medicaid | |
| WY | 1639426281 | Medicaid | |
| VA | 1639426281 | Medicaid | |
| MD | 4192451-02 | Medicaid | |
| NM | 10084550 | Medicaid | |
| AL | 150243 | Medicaid | |
| ID | 1639426281 | Medicaid | |
| NC | C201222100195-1 | Other | NORTH CAROLINA CERTIFICATE OF AUTHORITY (LLC) |
| AK | LB011NC | Medicaid | |
| WV | 3910005749 | Medicaid |
