Provider Demographics
NPI:1134559685
Name:ADVANTA GENETICS LLC
Entity type:Organization
Organization Name:ADVANTA GENETICS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:CARPENTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-805-9955
Mailing Address - Street 1:P.O. BOX 3488
Mailing Address - Street 2:DEPT 05-54
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803-3488
Mailing Address - Country:US
Mailing Address - Phone:903-805-9955
Mailing Address - Fax:903-839-2494
Practice Address - Street 1:10935 COUNTY ROAD 159
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-3333
Practice Address - Country:US
Practice Address - Phone:903-805-9955
Practice Address - Fax:903-839-2494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-20
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45D2063134OtherCLIA NUMBER
TX8863194OtherCAP