Healthcare Provider Details

I. General information

NPI: 1255797148
Provider Name (Legal Business Name): FPG LABS OF AUSTIN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2016
Last Update Date: 09/20/2021
Certification Date: 09/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 N MO PAC EXPY BUILDING 3, SUITE 3102
AUSTIN TX
78731-3282
US

IV. Provider business mailing address

15821 VENTURA BLVD SUITE 625
ENCINO CA
91436-4793
US

V. Phone/Fax

Practice location:
  • Phone: 512-610-7475
  • Fax:
Mailing address:
  • Phone: 818-858-1080
  • Fax: 323-729-3933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number45D1021548
License Number StateTX

VIII. Authorized Official

Name: GOLDIE GUPTA
Title or Position: CFO
Credential:
Phone: 630-536-7738