Provider Demographics
NPI:1154675742
Name:AGATHOS LABORATORIES, INC.
Entity Type:Organization
Organization Name:AGATHOS LABORATORIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:O
Authorized Official - Last Name:MOMOH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:408-730-6819
Mailing Address - Street 1:5201 GREAT AMERICA PKWY
Mailing Address - Street 2:SUITE 320
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95054-1122
Mailing Address - Country:US
Mailing Address - Phone:408-730-6819
Mailing Address - Fax:408-562-5745
Practice Address - Street 1:5201 GREAT AMERICA PKWY
Practice Address - Street 2:SUITE 320
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95054-1122
Practice Address - Country:US
Practice Address - Phone:408-730-6819
Practice Address - Fax:408-562-5745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-04
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGH102230817291900000X, 305S00000X, 332B00000X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No291900000XLaboratoriesMilitary Clinical Medical Laboratory
No305S00000XManaged Care OrganizationsPoint of Service
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies