Basic Information
| Provider Information | |||||||||
| NPI: | 1669141230 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INGENIOUS PERSONALIZED MEDICINE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1065 NE 125TH STREET | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | NORTH MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331615833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7862214228 | ||||||||
| FaxNumber: | 3058914228 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 APPLEYARD DRIVE TALLAHASSEE, FL 32304 | ||||||||
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| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323042810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7862211734 | ||||||||
| FaxNumber: | 3058914228 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2021 | ||||||||
| LastUpdateDate: | 09/08/2021 | ||||||||
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| AuthorizedOfficialLastName: | SEGAL | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | DANIEL | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8888526672 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 09/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.