1639957897 NPI number — GENESIS REFERENCE LABORATORIES, LLC

Table of content: (NPI 1639957897)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639957897 NPI number — GENESIS REFERENCE LABORATORIES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GENESIS REFERENCE LABORATORIES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639957897
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7924 FOREST CITY RD STE 210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32810-2925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-232-7172
Provider Business Mailing Address Fax Number:
407-289-4082

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6547 S RACINE CIR STE 1100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTENNIAL
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80111-6456
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-232-7172
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/19/2023

Additional Information

Authorized Official

Authorized Official Last Name:
FREITAS
Authorized Official First Name:
PHILIP
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
407-232-7172

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com