1134559685 NPI number — ADVANTA GENETICS LLC

Table of content: (NPI 1134559685)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134559685 NPI number — ADVANTA GENETICS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANTA GENETICS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134559685
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 3488
Provider Second Line Business Mailing Address:
DEPT 05-54
Provider Business Mailing Address City Name:
TUPELO
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38803-3488
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-805-9955
Provider Business Mailing Address Fax Number:
903-839-2494

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10935 COUNTY ROAD 159
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75703-3333
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-805-9955
Provider Business Practice Location Address Fax Number:
903-839-2494
Provider Enumeration Date:
11/20/2013

Additional Information

Authorized Official

Authorized Official Last Name:
CARPENTER
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
903-805-9955

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 45D2063134 . This is a "CLIA NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8863194 . This is a "CAP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 112991000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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