Provider Demographics
NPI:1790294908
Name:MITRA RXDX
Entity type:Organization
Organization Name:MITRA RXDX
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR. VP RA/QA
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:NOWLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:339-999-2300
Mailing Address - Street 1:12 GILL ST STE 3150
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-1777
Mailing Address - Country:US
Mailing Address - Phone:339-999-2300
Mailing Address - Fax:339-999-2399
Practice Address - Street 1:12 GILL ST STE 3150
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-1777
Practice Address - Country:US
Practice Address - Phone:339-999-2300
Practice Address - Fax:339-999-2399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNOT APPLICABLE