Provider Demographics
NPI:1982202453
Name:BEECHTREE MOLECULAR LAB LLC
Entity Type:Organization
Organization Name:BEECHTREE MOLECULAR LAB LLC
Other - Org Name:BT MOLECULAR LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-893-2773
Mailing Address - Street 1:12351 S GATEWAY PARK PL STE D-700
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-9581
Mailing Address - Country:US
Mailing Address - Phone:801-893-2773
Mailing Address - Fax:801-683-9907
Practice Address - Street 1:12351 S GATEWAY PARK PLACE
Practice Address - Street 2:SUITE D-500
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-8402
Practice Address - Country:US
Practice Address - Phone:269-998-0866
Practice Address - Fax:801-683-9907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-15
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT46D2209724OtherCLIA
AK02D2195732OtherCLIA