Provider Demographics
NPI:1992998157
Name:IVERSON GENETIC DIAGNOSTICS, INC.
Entity type:Organization
Organization Name:IVERSON GENETIC DIAGNOSTICS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:CLOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-284-7526
Mailing Address - Street 1:645 MEETING STREET
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403
Mailing Address - Country:US
Mailing Address - Phone:843-789-5912
Mailing Address - Fax:888-909-9784
Practice Address - Street 1:645 MEETING STREET
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403
Practice Address - Country:US
Practice Address - Phone:843-789-5912
Practice Address - Fax:888-909-9784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMTS-5156291U00000X
WAMTSC.FS.600017885291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA50D1072592OtherCLIA #
WA50D1083740OtherCLIA
WA7141252Medicaid
WA50D1083740OtherCLIA