Provider Demographics
NPI:1891811931
Name:IDAHO CYTOGENETICS DIAGNOSTIC LAB
Entity Type:Organization
Organization Name:IDAHO CYTOGENETICS DIAGNOSTIC LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDI
Authorized Official - Middle Name:K
Authorized Official - Last Name:BEACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-755-8700
Mailing Address - Street 1:PO BOX 78
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83707-0078
Mailing Address - Country:US
Mailing Address - Phone:208-376-8585
Mailing Address - Fax:
Practice Address - Street 1:2220 OLD PENITENTIARY RD
Practice Address - Street 2:STE 16
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-8249
Practice Address - Country:US
Practice Address - Phone:208-376-8585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1400782Medicare ID - Type Unspecified