Provider Demographics
NPI:1669791901
Name:PREDICTIVE BIOSCIENCES, INC.
Entity type:Organization
Organization Name:PREDICTIVE BIOSCIENCES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEMM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:781-402-1780
Mailing Address - Street 1:128 SPRING ST
Mailing Address - Street 2:400 LEVEL, B ANNEX
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-7848
Mailing Address - Country:US
Mailing Address - Phone:781-402-1780
Mailing Address - Fax:781-325-4939
Practice Address - Street 1:128 SPRING ST
Practice Address - Street 2:400 LEVEL, B ANNEX
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421-7848
Practice Address - Country:US
Practice Address - Phone:781-402-1780
Practice Address - Fax:781-325-4939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-26
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2929291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
22D1105541OtherCLIA ID