Healthcare Provider Details

I. General information

NPI: 1093337586
Provider Name (Legal Business Name): VANGAURD GENETICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2020
Last Update Date: 05/07/2020
Certification Date: 05/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3655 RESEARCH DRIVE MSC3ARP, GENESIS-B
LAS CRUCES NM
88003
US

IV. Provider business mailing address

3655 RESEARCH DRIVE MSC3ARP, GENESIS-B
LAS CRUCES NM
88003
US

V. Phone/Fax

Practice location:
  • Phone: 575-489-6688
  • Fax:
Mailing address:
  • Phone: 575-489-6688
  • Fax:

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. STEFAN ALFRED LONG
Title or Position: LABORATORY DIRECTOR
Credential: BS
Phone: 915-637-0087