=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184255606
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EXPRESS GENE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2020
-----------------------------------------------------
Last Update Date | 02/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9000 SW 152ND ST STE 209
-----------------------------------------------------
City | PALMETTO BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33157-1942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-250-3419
-----------------------------------------------------
Fax | 786-250-3074
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9000 SW 152ND STREET SUITE 209
-----------------------------------------------------
City | PALMETTO BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-250-3419
-----------------------------------------------------
Fax | 786-250-3074
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LABORATORY DIRECTOR
-----------------------------------------------------
Name | DR. MOHAMMAD ALI FAGHIHI
-----------------------------------------------------
Credential | M.D., PH.D.
-----------------------------------------------------
Telephone | 786-250-3419
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------