Provider Demographics
NPI:1316555204
Name:IMMUNOGENOMICS LLC
Entity Type:Organization
Organization Name:IMMUNOGENOMICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:TWINKLE
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MSC
Authorized Official - Phone:850-849-2554
Mailing Address - Street 1:4502 ROYAL BEND LN
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-1564
Mailing Address - Country:US
Mailing Address - Phone:850-849-2554
Mailing Address - Fax:
Practice Address - Street 1:202 INDUSTRIAL BLVD STE 501
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-2702
Practice Address - Country:US
Practice Address - Phone:850-849-2554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-17
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory