Provider Demographics
NPI:1629735519
Name:AXIOM BIOGENOMICS, LLC
Entity Type:Organization
Organization Name:AXIOM BIOGENOMICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DONOVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:539-666-3310
Mailing Address - Street 1:7335 S LEWIS AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-6830
Mailing Address - Country:US
Mailing Address - Phone:539-666-3310
Mailing Address - Fax:972-848-1362
Practice Address - Street 1:7335 S LEWIS AVE STE 120
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-6830
Practice Address - Country:US
Practice Address - Phone:539-666-3310
Practice Address - Fax:972-848-1362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-26
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK37D2172910OtherCLIA