Provider Demographics
NPI:1437544038
Name:ADVANCED GENOMICS, LLC
Entity Type:Organization
Organization Name:ADVANCED GENOMICS, LLC
Other - Org Name:FULL SPECTRUM LABORATORIES, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCDC
Authorized Official - Phone:210-627-4017
Mailing Address - Street 1:10750 HAMMERLY BLVD STE 259
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77043-2318
Mailing Address - Country:US
Mailing Address - Phone:210-627-4017
Mailing Address - Fax:210-579-6873
Practice Address - Street 1:10750 HAMMERLY BLVD STE 120
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77043-2317
Practice Address - Country:US
Practice Address - Phone:210-627-4017
Practice Address - Fax:210-579-6873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-31
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS370837OtherMEDICAID
TX45D2092474OtherCLIA
TX423612Medicaid