Provider Demographics
NPI:1811341217
Name:GULFSTREAM GENOMICS LLC
Entity type:Organization
Organization Name:GULFSTREAM GENOMICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF LEGAL
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VISKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:972-630-6443
Mailing Address - Street 1:9301 N CENTRAL EXPY
Mailing Address - Street 2:STE 335
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-0806
Mailing Address - Country:US
Mailing Address - Phone:972-640-6400
Mailing Address - Fax:
Practice Address - Street 1:9301 N CENTRAL EXPY
Practice Address - Street 2:STE 335
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-0806
Practice Address - Country:US
Practice Address - Phone:972-640-6400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-21
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D2096977291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory