Basic Information
| Provider Information | |||||||||
| NPI: | 1114344983 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTELLIGENETICS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3480 EASTERN BLVD | ||||||||
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| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361161700 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 24 NEW ORLEANS RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | HILTON HEAD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299284721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3348194500 | ||||||||
| FaxNumber: | 3348194520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2014 | ||||||||
| LastUpdateDate: | 02/24/2015 | ||||||||
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| AuthorizedOfficialLastName: | GREEN | ||||||||
| AuthorizedOfficialFirstName: | JANUARY | ||||||||
| AuthorizedOfficialMiddleName: | MILLER | ||||||||
| AuthorizedOfficialTitleorPosition: | VP, HR | ||||||||
| AuthorizedOfficialTelephone: | 3348194500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 8038983432 | SC | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.