Provider Demographics
NPI:1548495575
Name:INDIVIDUALIZED TREATMENT TECHNOLOGIES LABORATORIES
Entity type:Organization
Organization Name:INDIVIDUALIZED TREATMENT TECHNOLOGIES LABORATORIES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-930-0001
Mailing Address - Street 1:4112 AUTUMN LN
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35243-5208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1601 12TH AVE S
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205-4709
Practice Address - Country:US
Practice Address - Phone:205-930-0001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-20
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL01D1099109291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory