Provider Demographics
NPI:1841715471
Name:PACGENOMICS
Entity type:Organization
Organization Name:PACGENOMICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-292-7411
Mailing Address - Street 1:1544 SAWDUST RD STE 280
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77380-2986
Mailing Address - Country:US
Mailing Address - Phone:281-292-7411
Mailing Address - Fax:281-292-7481
Practice Address - Street 1:28222 AGOURA RD
Practice Address - Street 2:STE 200/2001
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-2411
Practice Address - Country:US
Practice Address - Phone:818-597-1938
Practice Address - Fax:818-597-1939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-04
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory