Healthcare Provider Details

I. General information

NPI: 1467793208
Provider Name (Legal Business Name): CGC GENETICS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2013
Last Update Date: 03/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 S ORANGE AVE F661
NEWARK NJ
07103-2757
US

IV. Provider business mailing address

185 S ORANGE AVE F661
NEWARK NJ
07103-2757
US

V. Phone/Fax

Practice location:
  • Phone: 973-623-1264
  • Fax: 973-623-1266
Mailing address:
  • Phone: 973-623-1264
  • Fax: 973-623-1266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberCOS00800249
License Number StateCA

VIII. Authorized Official

Name: PROF. PURIFICACAO TAVARES
Title or Position: CEO
Credential: M.D., PHD
Phone: 973-623-1264