Provider Demographics
NPI:1447911409
Name:BOULDER GX
Entity type:Organization
Organization Name:BOULDER GX
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:ZACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-225-8417
Mailing Address - Street 1:25003 PITKIN RD STE F300
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77386-1523
Mailing Address - Country:US
Mailing Address - Phone:866-648-1117
Mailing Address - Fax:
Practice Address - Street 1:25003 PITKIN RD STE F300
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77386-1523
Practice Address - Country:US
Practice Address - Phone:866-648-1117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-03
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory