=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457187296
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROSTATYPE GENOMICS INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2024
-----------------------------------------------------
Last Update Date | 09/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5 MASON STE 190
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-2552
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-681-6626
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 MASON STE 190
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-2552
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-681-6626
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT-US OPERATIONS
-----------------------------------------------------
Name | MR. STEVEN GAAL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-681-6626
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------