Provider Demographics
| NPI: | 1730481078 |
|---|---|
| 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: | VICE PRESIDENT |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | KIMBERLY |
| Authorized Official - Middle Name: | T |
| Authorized Official - Last Name: | WILLIAMS |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 800-222-7566 |
| 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: | 3595 JOHN HOPKINS CT |
| Practice Address - Street 2: | |
| Practice Address - City: | SAN DIEGO |
| Practice Address - State: | CA |
| Practice Address - Zip Code: | 92121-1121 |
| 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: | 2010-11-18 |
| Last Update Date: | 2017-07-20 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| CA | CLF00339964 | 291U00000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization |
|---|---|---|---|---|
| Yes | 291U00000X | Laboratories | Clinical Medical Laboratory |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| GA | 003115419A | Medicaid | |
| CA | 05D2015356 | Other | CLIA |
| VT | 1020915 | Medicaid | |
| PA | 102377695-002 | Medicaid | |
| MD | 1728 | Other | MARYLAND MEDICAL LABORATORY PERMIT |
| WY | 1730481078 | Medicaid | |
| MI | 1730481078 | Medicaid | |
| FL | 800026127 | Other | STATE OF FLORIDA CLINICAL LABORATORY LICENSE |
| TN | 1527595 | Medicaid | |
| MN | 1730481078 | Medicaid | |
| OK | 200311320B | Medicaid | |
| WA | 2017818 | Medicaid | |
| LA | 2192639 | Medicaid | |
| KY | 7100190660 | Medicaid | |
| 7527138 | Other | COLLEGE OF AMERICAN PATHOLOGISTS (CAP) | |
| IL | 770365889-002 | Medicaid | |
| CO | 92038026 | Medicaid | |
| SC | L00343 | Medicaid | |
| PA | 032136 | Other | STATE OF PENNSYLVANIA CLINICAL LABORATORY LICENSE |
| ME | 1730481078 | Medicaid | |
| NY | 3708683 | Medicaid | |
| DC | 71028300 | Medicaid | |
| NY | PFI: 8557 | Other | STATE OF NEW YORK CLINICAL LABORATORY PERMIT |
| IA | 1730481078 | Medicaid | |
| UT | 1730481078 | Medicaid | |
| KS | 200656570 B | Medicaid | |
| MD | 4192451 01 | Medicaid | |
| NE | 10026203300 | Medicaid | |
| AL | 137226 | Medicaid | |
| ID | 1730481078 | Medicaid | |
| NH | 30809688 | Medicaid | |
| NC | 7001452 | Medicaid | |
| CA | CLF00339964 | Other | CLINICAL LABORATORY LICENSE |
| AK | LB011CA | Medicaid | |
| WV | 3810023520 | Medicaid | |
| FL | 004122500 | Medicaid | |
| VA | 1730481078 | Medicaid | |
| MO | 1730481078 | Medicaid | |
| CT | 1730481078 | Medicaid | |
| NM | 20123744 | Medicaid | |
| NJ | 296651 | Medicaid | |
| TX | 323717401 | Medicaid | |
| MS | 6231868 | Medicaid | |
| AZ | 660597 | Medicaid | |
| OH | 0056345 | Medicaid | |
| WI | 100022595 | Medicaid | |
| MT | 1730481078 | Medicaid | |
| IN | 200958790 B | Medicaid | |
| CA | FV093A | Other | MEDICARE PTAN |
| RI | LCO 00657 | Other | RHODE ISLAND CLINICAL LABORATORY LICENSE |
