Provider Demographics
NPI:1710782388
Name:INFORM DIAGNOSTICS, INC.
Entity type:Organization
Organization Name:INFORM DIAGNOSTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP, GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:WICKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-477-4402
Mailing Address - Street 1:1111 S FREEPORT PKWY
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-4435
Mailing Address - Country:US
Mailing Address - Phone:888-290-5307
Mailing Address - Fax:
Practice Address - Street 1:827 GROVE VIEW RD
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92057-2202
Practice Address - Country:US
Practice Address - Phone:888-290-5307
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INFORM DIAGNOSTICS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-02-17
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty