Healthcare Provider Details

I. General information

NPI: 1154675742
Provider Name (Legal Business Name): AGATHOS LABORATORIES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2012
Last Update Date: 01/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 GREAT AMERICA PKWY SUITE 320
SANTA CLARA CA
95054-1122
US

IV. Provider business mailing address

5201 GREAT AMERICA PKWY SUITE 320
SANTA CLARA CA
95054-1122
US

V. Phone/Fax

Practice location:
  • Phone: 408-730-6819
  • Fax: 408-562-5745
Mailing address:
  • Phone: 408-730-6819
  • Fax: 408-562-5745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291900000X
TaxonomyMilitary Clinical Medical Laboratory
License NumberGH102230817
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License NumberGH102230817
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberGH102230817
License Number StateCA

VIII. Authorized Official

Name: DR. PAUL O MOMOH
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 408-730-6819