MEDICARE: PRECISION GENOMICS LLC

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

General Provider Information

NPI Number	:	1407718430
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRECISION GENOMICS LLC

Provider Business Mailing Address
First Line	:	4850 GOODMAN RD STE 101
Second Line	:
City	:	OLIVE BRANCH
State	:	MS
Zip	:	38654-7906
Country	:	US
Telephone Number	:	662-350-4485
Fax Number	:

Provider Business Practice Location Address
First Line	:	4850 GOODMAN RD STE 101
Second Line	:
City	:	OLIVE BRANCH
State	:	MS
Zip	:	38654-7906
Country	:	US
Telephone Number	:	662-350-4485
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RACHEL WISEMAN
Credential	:
Telephone Number	:	615-727-2412

Provider Enumeration Date	:	11/28/2025
Last Update Date	:	06/08/2026

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