Healthcare Provider Details

I. General information

NPI: 1346713989
Provider Name (Legal Business Name): GENOMIC TESTING COOPERATIVE LCA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2019
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25371 COMMERCENTRE DR
LAKE FOREST CA
92630-8859
US

IV. Provider business mailing address

25371 COMMERCENTRE DR
LAKE FOREST CA
92630-8859
US

V. Phone/Fax

Practice location:
  • Phone: 949-540-9421
  • Fax: 949-301-9719
Mailing address:
  • Phone: 657-202-5951
  • Fax: 949-301-9719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MR. LAWRENCE ECK
Title or Position: COO
Credential:
Phone: 657-202-5951