Provider Demographics
NPI:1912903717
Name:DOMINION DIAGNOSTICS, LLC
Entity Type:Organization
Organization Name:DOMINION DIAGNOSTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PAYER RELATIONS REP
Authorized Official - Prefix:
Authorized Official - First Name:BRANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-734-6392
Mailing Address - Street 1:211 CIRCUIT DRIVE
Mailing Address - Street 2:
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-7440
Mailing Address - Country:US
Mailing Address - Phone:877-734-9600
Mailing Address - Fax:401-667-0330
Practice Address - Street 1:211 CIRCUIT DRIVE
Practice Address - Street 2:
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-7440
Practice Address - Country:US
Practice Address - Phone:877-734-9600
Practice Address - Fax:401-667-0330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-27
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI00343291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
49D0926092OtherCLIA
1334975OtherCAP AU-ID
7029901OtherCAP LAP NUMBER
699002807Medicare ID - Type UnspecifiedPART B CARRIER