Healthcare Provider Details

I. General information

NPI: 1245812288
Provider Name (Legal Business Name): MYGENOMEMYLIFEMGML
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1629 K ST NW STE 300NW
WASHINGTON DC
20006-1602
US

IV. Provider business mailing address

1629 K ST NW STE 300NW
WASHINGTON DC
20006-1602
US

V. Phone/Fax

Practice location:
  • Phone: 202-476-0727
  • Fax:
Mailing address:
  • Phone: 202-476-0727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247000000X
TaxonomyHealth Information Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DEEPTI GUPTA
Title or Position: ADMINISTRATOR
Credential:
Phone: 513-666-2440