1801226543 NPI number — GENEX LABORATORY PROFESSIONAL CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801226543 NPI number — GENEX LABORATORY PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GENEX LABORATORY PROFESSIONAL CORPORATION
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:
6
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:
1801226543
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3151 AIRWAY AVE STE M1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COSTA MESA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92626-4626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-610-7253
Provider Business Mailing Address Fax Number:
949-610-7253

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3151 AIRWAY AVE STE M1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COSTA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92626-4626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-610-7253
Provider Business Practice Location Address Fax Number:
949-610-7253
Provider Enumeration Date:
11/15/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BURGESS
Authorized Official First Name:
DAMIEN
Authorized Official Middle Name:
JOHANN
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
949-610-7253

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  CLF 00345153 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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