Individualized Treatment Technologies Laboratories, LLC

Primary specialty

Clinical Medical LaboratoryTaxonomy code 291U00000X

License

L45100 Issued in AL

Legal business name

INDIVIDUALIZED TREATMENT TECHNOLOGIES LABORATORIES, LLC

Practice address

2705 Artie St SW
Building 400 Suite 25
Huntsville, AL 35805-4761

Phone

(256) 434-5160

Fax

(205) 930-0082

NPI assigned

Jun 13, 2013

Last updated

Apr 5, 2017By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Johnny L. Stoddard

Title

President and Ceo

Phone

(256) 714-2105

Specialties & licenses 2

Addresses

Other identifiers 12

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1371081600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1491350400000",
    "number": "1043658966",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "303 WILLIAMS AVE SW",
            "address_2": "SUITE 135",
            "city": "HUNTSVILLE",
            "state": "AL",
            "postal_code": "358016012",
            "telephone_number": "855-436-6728",
            "fax_number": "256-489-7134"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2705 ARTIE ST SW",
            "address_2": "BUILDING 400 SUITE 25",
            "city": "HUNTSVILLE",
            "state": "AL",
            "postal_code": "358054761",
            "telephone_number": "256-434-5160",
            "fax_number": "205-930-0082"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INDIVIDUALIZED TREATMENT TECHNOLOGIES LABORATORIES, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-06-13",
        "last_updated": "2017-04-05",
        "status": "A",
        "authorized_official_last_name": "STODDARD",
        "authorized_official_first_name": "JOHNNY",
        "authorized_official_middle_name": "L.",
        "authorized_official_title_or_position": "PRESIDENT AND CEO",
        "authorized_official_telephone_number": "256-714-2105",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": "AL",
            "license": "L37174",
            "primary": false
        },
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": "AL",
            "license": "L45100",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0544256",
            "state": "NJ"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "08976741",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1043658966",
            "state": "MI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3578338",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "82987564",
            "state": "NM"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "103155",
            "state": "AZ"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "185597",
            "state": "AL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "201369650A",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "212246709",
            "state": "AR"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "L00494",
            "state": "SC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1043658966",
            "state": "IL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7100419330",
            "state": "KY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Clinical Medical Laboratory in Huntsville, AL
• Providers in Huntsville, AL by specialty
• Clinical Medical Laboratory in Alabama

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 5, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.