Provider Demographics
NPI:1629531769
Name:INNOVATIVE GENOMICS LLC
Entity Type:Organization
Organization Name:INNOVATIVE GENOMICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DIEGO
Authorized Official - Middle Name:SANCHEZ SANUDO
Authorized Official - Last Name:CHOCRON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-985-2834
Mailing Address - Street 1:5410 FREDERICKSBURG RD STE 304
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3576
Mailing Address - Country:US
Mailing Address - Phone:210-351-5175
Mailing Address - Fax:210-352-5175
Practice Address - Street 1:5410 FREDERICKSBURG RD
Practice Address - Street 2:SUITE 304
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229
Practice Address - Country:US
Practice Address - Phone:210-352-5175
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-06
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45D2155835OtherCLIA