Provider Demographics
NPI:1518610120
Name:GENOMIC PREDICTION CLINICAL LABORATORY, INC.
Entity type:Organization
Organization Name:GENOMIC PREDICTION CLINICAL LABORATORY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:KETTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-612-6332
Mailing Address - Street 1:671 US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:NORTH BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08902-3360
Mailing Address - Country:US
Mailing Address - Phone:973-529-4223
Mailing Address - Fax:
Practice Address - Street 1:671 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:NORTH BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08902-3360
Practice Address - Country:US
Practice Address - Phone:973-529-4223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-02
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory