Provider Demographics
NPI:1912684929
Name:INTEGRATED MOLECULAR DIAGNOSTICS PATHOLOGY, INC.
Entity Type:Organization
Organization Name:INTEGRATED MOLECULAR DIAGNOSTICS PATHOLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ISRAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLASENOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-818-4051
Mailing Address - Street 1:2855 TELEGRAPH AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-1153
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4150 TRUXEL RD STE C
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95834-3761
Practice Address - Country:US
Practice Address - Phone:510-849-6189
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTEGRATED MOLECULAR DIAGNOSTICS PATHOLOGY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-06-30
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory