Provider Demographics
NPI:1659663656
Name:INFLAMMATORY MARKERS LABORATORY, LLC
Entity Type:Organization
Organization Name:INFLAMMATORY MARKERS LABORATORY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:E
Authorized Official - Last Name:ENS
Authorized Official - Suffix:
Authorized Official - Credentials:MT(ASCP)
Authorized Official - Phone:316-680-3330
Mailing Address - Street 1:21 TIOGA WAY
Mailing Address - Street 2:
Mailing Address - City:MARBLEHEAD
Mailing Address - State:MA
Mailing Address - Zip Code:01945-1577
Mailing Address - Country:US
Mailing Address - Phone:781-990-0616
Mailing Address - Fax:
Practice Address - Street 1:21 TIOGA WAY
Practice Address - Street 2:
Practice Address - City:MARBLEHEAD
Practice Address - State:MA
Practice Address - Zip Code:01945-1577
Practice Address - Country:US
Practice Address - Phone:781-990-0616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-09
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5251291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory