Provider Demographics
NPI:1770977951
Name:INTEGRATED MOLECULAR DIAGNOSTICS PATHOLOGY, INC.
Entity type:Organization
Organization Name:INTEGRATED MOLECULAR DIAGNOSTICS PATHOLOGY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT/SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:ISRAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLASENSOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-818-4051
Mailing Address - Street 1:1900 THE ALAMEDA
Mailing Address - Street 2:STE 530
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-1437
Mailing Address - Country:US
Mailing Address - Phone:831-818-4051
Mailing Address - Fax:866-550-3288
Practice Address - Street 1:12635 E MONTVIEW BLVD
Practice Address - Street 2:STE 360
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-7335
Practice Address - Country:US
Practice Address - Phone:303-961-1773
Practice Address - Fax:866-550-3288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO195377291U00000X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory