Provider Demographics
NPI:1669484473
Name:MYRIAD GENETIC LABORATORIES, INC.
Entity Type:Organization
Organization Name:MYRIAD GENETIC LABORATORIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:B
Authorized Official - Last Name:ROA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:801-584-3049
Mailing Address - Street 1:320 WAKARA WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1214
Mailing Address - Country:US
Mailing Address - Phone:801-584-3600
Mailing Address - Fax:801-883-3472
Practice Address - Street 1:320 WAKARA WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1214
Practice Address - Country:US
Practice Address - Phone:801-584-3600
Practice Address - Fax:801-883-3472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT46D0880690291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02668124Medicaid
CO56130236Medicaid
WI82350800Medicaid
MD409661400Medicaid
AZ912768Medicaid
VA010210186Medicaid
OK200062220AMedicaid
UT46D2094383OtherCLIA
AKLB323UTMedicaid
NM42122333Medicaid
UT46D2094383Medicaid
MO706248507Medicaid
IN200508920AMedicaid
AZ912768Medicaid