Provider Demographics
NPI:1750668703
Name:EVERIST GENOMICS, INC.
Entity Type:Organization
Organization Name:EVERIST GENOMICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:THEISEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-929-6305
Mailing Address - Street 1:709 W ELLSWORTH RD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-3371
Mailing Address - Country:US
Mailing Address - Phone:734-929-6302
Mailing Address - Fax:734-929-9477
Practice Address - Street 1:709 W ELLSWORTH RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-3371
Practice Address - Country:US
Practice Address - Phone:734-929-6302
Practice Address - Fax:734-929-9501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-04
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI23D20178291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory