MEDICARE: GENOMIC TESTING COOPERATIVE LCA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	05D2111917	OTHER		CLIA

General Provider Information

NPI Number	:	1346713989
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENOMIC TESTING COOPERATIVE LCA

Provider Business Mailing Address
First Line	:	25371 COMMERCENTRE DR
Second Line	:
City	:	LAKE FOREST
State	:	CA
Zip	:	92630-8859
Country	:	US
Telephone Number	:	657-202-5951
Fax Number	:	949-301-9719

Provider Business Practice Location Address
First Line	:	25371 COMMERCENTRE DR
Second Line	:
City	:	LAKE FOREST
State	:	CA
Zip	:	92630-8859
Country	:	US
Telephone Number	:	949-540-9421
Fax Number	:	949-301-9719

Authorized Official
Title or Position	:	COO
Name	:	MR. LAWRENCE ECK
Credential	:
Telephone Number	:	657-202-5951

Provider Enumeration Date	:	01/07/2019
Last Update Date	:	06/28/2024

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