Provider Demographics
NPI:1710499132
Name:ILIAD NEUROSCIENCES INC.
Entity Type:Organization
Organization Name:ILIAD NEUROSCIENCES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-434-8523
Mailing Address - Street 1:5110 CAMPUS DR STE 190
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH MEETING
Mailing Address - State:PA
Mailing Address - Zip Code:19462-1143
Mailing Address - Country:US
Mailing Address - Phone:610-441-9050
Mailing Address - Fax:
Practice Address - Street 1:5110 CAMPUS DR STE 190
Practice Address - Street 2:
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-1143
Practice Address - Country:US
Practice Address - Phone:610-441-9050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory